LIBRARY 

THE  UNIVERSITY 
OF  CALIFORNIA 

SANTA  BARBARA 

PRESENTED  BY 

DONALD  BEEKS 


Hubert  Sauhott  Sail 


MENTAL  HYGIENE 

Two  Years'  Experience  of  a  Clinical  Psychologist 


I  MENTAL  HYGIENE 

Two  Years'  Experience  of  a  Clinical  Psychologist 


By 

LILLIEN  J.  MARTIN,  Ph.  D. 


BALTIMORE 

WARWICK  &  YORK,  Inc. 
1920 


V"» 


Copyright.  1920 
By  WARWICK  &  YORK.  Inc. 


To  the  Memory  of  my  Friends 
William  James  and  Oswald  Kulpe 


PREFACE 

Up  to  the  present  time  the  clinical  psychologist  has  largely 
confined  his  work  to  diagnosis — not  to  the  diagnosis  of  in- 
dividuals or  of  all  classes  of  mental  irregularities,  but  par- 
ticularly to  separating  out  one  class  of  people,  the  feeble- 
minded— without  even  here  having  made  any  very  search- 
ing individual  study. 

The  medical  profession  has  now  largely  accorded  to  the 
clinical  psychologist  the  work  of  a  clearing  house  as  re- 
gards the  feeble-minded,  but  there  is  too  great  a  tendency  on 
its  part  to  accept  the  clinical  phychologist's  self-imposed 
limitations  as  regards  the  field  of  work  and  to  expect  him 
to  leave  therapeutic  and  preventative  mental  hygiene  fields 
for  the  most  part  untouched.  When  I  opened  an  office  in 
San  Francisco  as  clinical  psychologist,  I  determined  if  pos- 
sible not  only  to  broaden  out  the  work  in  mental  hygiene 
so  as  to  include  the  two  last  mentioned  fields,  but  also  to  ascer- 
tain from  actual  experience  whether  the  clinical  psychologist 
has  a  place,  not  alone  as  simultaneous  accompanier  and  sup- 
plementor  of  the  work  of  the  general  medical  practitioner, 
but  as  an  independent  worker,  in  increasing  the  health  and 
efficiency  of  the  community.  The  beneficial  results  coming 
from  applying  general  psychological  principles  and  labora- 
tory experience  in  a  therapeutic  way  during  the  last  two 
years,  have  shown  me  conclusively  that  the  clinical  psychol- 
ogist ought  to  have  in  the  future  a  much  wider  field  than 
he  has  previously  had. 

729  Jones  Street,  I,,  j.  M. 

San  Francisco,  March,  1920. 


CONTENTS 

PAGE 

Preface     vii 

Introduction     , I 

CHAPTER   I. 

Distribution  of  Consulters  as  to  Sex,  Age,  and  Place  of  Con- 
sultation    7 

CHAPTER  2. 

The  Mental  and  Physical  Examination  of  the  Consulters 9 

CHAPTER  3. 

Classification  of  the  Mental  Disturbances  of  the  Consulters 
and  Summary  of  the  General  Manner  of  Handling  the 
Various  Classes 14 

CHAPTER  4. 
The    Psychodiagnostic    and    Psychotherapeutic    Modes    of 

Treatment    Employed 36 

CHAPTER  5. 
The   Method  of  Re-Education 44 

CHAPTER  6. 
A  Discussion  of  Some  Typical  Cases 61 

CHAPTER   7- 

The  Part  of  the  Social  Worker  in  Mental  Hygiene  Diagnosis 

and   Treatment 68 

CHAPTER  8. 

The  Effect  of  the  Mental  Hygiene  Treatment  on  the  Con- 
suiters 73 

CHAPTER  9. 

Preventative   Mental  Hygiene 78 

Conclusion    85 


INTRODUCTION 

In  February,  1917,  I  opened  an  office  in  San  Francisco, 
as  consulting  psychologist.  In  view  of  the  newness  of  the 
work  in  applied  psychology  it  has  seemed  to  me  that  a  sum- 
mary of  the  number  of  consumers,  the  mental  difficulties 
which  led  them  to  seek  psychological  advice,  and  the  diag- 
nosis and  treatment  given  them,  might  be  of  interest  and 
possibly  of  use  to  others. 

Publicity.  The  first  problem  that  contronts  one  in  open- 
ing an  office  of  this  kind  is  how  to  acquaint  people  with  the 
nature  of  mental  hygiene  work.  In  view  of  the  custom 
in  medical  practice  and  the  fact  that  one  wishes  to  get  the 
support  of  physicians,  it  is  desirable,  of  course,  to  avoid  di- 
rect advertising.  The  indirect  advertising  that  comes 
through  informing  the  public  what  mental  hygiene  is,  by 
means  of  interviews  with  newspapermen  seemed  to  me  legit- 
imate, and  I  therefore  received  two  reporters  who  wished  to 
discuss  the  matter  with  me.  Lectures  on  the  subject  were  also 
given  and  my  professional  card,  and  the  following  circulars 
were  sent  to  physicians  and  acquaintances : 

THE  AIM  OF  A  MENTAL  HYGIENIC  ADVISER  IS 

To  decrease  the  mental  disturbances  growing  out  of  a  severe 
emotional  strain ;  to  banish  abnormal  persistent  ideas ;  to  do 
away  with  some  of  the  mental  disturbances  of  the  stress 
periods  of  adolesence,  change  of  life,  and  old  age;  to  increase 
a  person's  power  along  the  lines  of  observation,  attention  in- 
cluding concentration,  memory  and  will;  to  eliminate  injurious 
mental  and  physical  habits;  to  get  rid  of  distressing  dreams  and 
sleeplessness ;  to  destroy  the  painful  and  paralyzing  mental 
after-effects  which  sometimes  follow  a  successful  operation  and 
the  cure  of  a  disease ;  and  to  prevent  and  overcome  the  forma- 
tion of  alcohol  and  drug  habits. 

To  assist  in  the  protection,  proper  care  and  education  of 
insane  and  feeble-minded  persons. 

To  aid  mothers  and  teachers  in  educating  and  managing,  not 
alone  their  nervous  children,  but  also  those  who  are  healthy, 
through  applying  the  results  of  recent  investigations  in  psy- 
chology along  the  lines  of  heredity  and  mental  diseases. 


2  MENTAL  HYGIENE 

To  help  in  the  personal  application  of  some  of  the  more 
recent  studies  of  unnecessary  fatigue. 

To  assist  students  and  others  to  adjust  themselves  to  their 
work,  and  to  aid  in  the  selection  or  change  of  a  vocation;  in 
general,  to  help  people  to  increase  their  efficiency  and  happiness. 

In  order  to  let  any  one  who  thought  of  consulting  me, 
see  that  I  had  had  thorough  psychological  training,  I  occa- 
sionally sent  out  later  the  biographical  sketch  below,  which 
has  appeared  in  "Who's  Who,"  and  elsewhere,  with  the 
above  circular.  This  was  done  partly  also  to  avoid  unnec- 
essary interruptions,  as  I  found  that  certain  untrained  per- 
sons (mental  healers  of  various  sorts,  psychopaths,  etc.,) 
"dropped  in"  my  office  to  discuss  "our  common  work."  These 
persons  had  had  a  different  preparation  for  the  work  of 
mental  hygiene  and  their  ideals  were  so  far  removed  from 
mine,  that  I  soon  found  I  had  nothing  to  give  them,  nor 
could  I  get  anything  of  value  from  them. 

MARTIN,  LILLIEN  JANE,  born  at  Clean,  N.  Y.,  1851; 
A.  B.  Vassar  College,  1880;  U.  of  Gottingen,  1984-1898;  Hon. 
Ph.D.  Univ,  of  Bonn,  1913.  The  honorary  degree  was  con- 
ferred upon  Dr.  Martin,  the  diploma  says,  because  she  had  in- 
troduced into  psychology  a  method  through  which  it  is  pos- 
sible to  make  a  comparison  between  an  image  and  the  cor- 
responding sensation ;  for  inventing  a  new  psychological 
method — the  Projection  Method;  for  introducing  into  psychol- 
ogy a  method  of  measuring  imageless  thought;  for  putting  the 
Suggestion-Method  on  a  scientific  basis ;  for  testing  for  the 
first  time  experimentally  Fechner's  aesthetic  laws ;  for  making 
the  first  experimental  study  of  the  Comic;  for  investigating 
experimentally  certain  current  theories  in  Aesthetics,  as  those  of 
Gross,  Hegel,  etc. ;  and  for  testing  by  experiment  the  theories 
of  the  subconscious,  of  Binet,  Meyer,  Freud  and  Prince ;  for 
her  investigation  with  Miiller  on  the  Analysis  of  the  Sensi- 
bility to  Difference,  of  which  one  of  the  most  eminent  living 
American  Psychologists  says :  "There  can  be  no  doubt  that 
the  work  of  Martin  and  Miiller  will  stand  as  a  landmark  in  the 
history  of  experimental  psychology — comparable,  perhaps,  with 
such  books  as  Hering's  Lichtsinn  or  Ebbinhaus."  Science  teacher 
Indianapolis  High  School,  1880-9;  vice  principal  and  head  of 
department  of  science,  Girls'  High  School,  San  Francisco, 
1889-94;  Professor  of  Psychology,  1899-1916,  Leland  Stan- 


INTRODUCTION  3 

ford  Junior  University,  when  she  became  Professor  Emeritus, 
and  opened  an  office  in  San  Francisco  as  consulting  psychol- 
ogist. Wellow  of  A.  A.'A.  S.  Member  of  Kongress  fiir  experi- 
mentelle  Psychologic.  American  Psychological  Association; 
Sigma  XI;  Honorary  member  of  Century  Club  of  California; 
President  California  Branch  of  the  Association  of  Colle- 
giate Alumnas,  1892;  President  College  Equal  Suffrage  League, 
1912;  Vice- President  Section  H,  of  the  American  Association 
for  the  Advancement  of  Science,  1914-15;  President  of  the 
California  Society  for  Mental  Hygiene,  1917. 

The  response  to  the  first  circular  was  immediate.  The 
number  of  consulters  has  increased  from  month  to  month. 
The  total  number  of  persons  coming  for  consultation  was 
500,  and  the  whole  number  of  visits  1400-1500,  that  is  ap- 
proximately three  visits  for  each  consulter. 

Among  those  who  came  for  consultation  were  persons 
who  felt  depressed,  anxious,  or  worried,  or  had  lost  their 
interest  in  life  or  their  ambition;  those  who  felt  they  were 
breaking  down  mentally ;  those  who  were  extremely  nervous, 
irritable  and  even  fretful,  or  suffering  from  insomnia ;  those 
who  found  everything  in  life  against  them ;  those  who  knew 
that  something  was  wrong  with  them  mentally  and  wished 
to  know  what  it  was;  individuals  who  found  their  daily 
work  to  be  a  burden  and  that  living  was  getting  to  be  too 
great  a  tax  upon  them;  those  who  had  become  doubtful  of 
their  own  ability  to  deal  with  a  business  situation  and  were, 
therefore,  afraid  to  take  the  initiatory  steps  necessary; 
those  who  sought  aid  because  they  realized  that  they  had 
not  the  knowledge  required  to  cope  adequately  with  their 
children  and  many  other  family  problems.  The  mother 
came  to  ascertain  why  her  child  was  not  doing  satisfactory 
work  in  school,  to  get  assistance  in  dealing  with  the  un- 
stable and  stress  period  of  adolescence,  in  selecting  a  vocation 
fitted  to  the  difficult  environment  in  which  she  found  her- 
self, and  in  overcoming  the  confused  mental  condition  and 
the  melancholy  feelings  accompanying  the  stress  of  the 


4  MENTAL  HYGIENE 

menapause  and  old  age.  Others  whom  I  saw  were  persons 
having  difficulty  in  controlling  their  thoughts  or  emotions, 
or  who  had  lost  the  ability  to  hold  their  attention  to  the 
work  in  hand,  or  had  found  that  their  memories  were  weak- 
ening ;  melancholy  persons ;  "shut-in"  personalities  avoiding 
the  society  of  others  and  feeling  that  they  were  misunder- 
stood, slighted,  or  shunned  by  their  family  and  friends; 
neurasthenics  who  lacked  the  initiative  to  find  and  hold  a 
position;  those  who  found  that  they  were  not  in  an  em- 
ployment suited  to  them  and  sought  advice  as  to  what  they 
were  really  fitted  to  do;  young  people  who  wanted  help  in 
choosing  a  vocation;  excitable,  irresponsible,  high-strung, 
uncontrolled  persons;  psychopathic  individuals  and  insane 
persons ;  the  prematurely  old ;  adolescent  boys  and  girls, 
sometimes  hysterical,  who  were  not  understood  by  them- 
selves or  by  those  around  them,  and  longed  for  sympathy 
and  guidance;  backward,  feeble-minded  children  who  had 
stolen;  children  difficult  to  control  at  home  and  at  school; 
parents  who  not  only  took  too  much  alcohol  themselves,  but 
were  even  giving  it  to  their  children;  those  whose  families 
were  at  the  point  of  disruption.  All  were  not  ignorant  or 
poor — among  them  were  a  college  professor,  an  influential 
business  man,  a  leading  newspaper  writer,  and  an  editor. 
In  short,  people  came  who  wished  to  increase  not  alone  their 
happiness,  but  also  their  effectiveness.  Unfortunately,  in- 
formation giving  and  advertising  in  regard  to  mental 
hygiene  work  must  be  more  or  less  kept  up,  as  the  advertis- 
ing which  comes  through  one  consulter's  telling  another  that 
he  has  been  helped  by  a  given  psychologist  is  very  much  less 
than  in  the  case  of  the  patient  of  a  physician,  as  consulters 
hesitate  to  say  that  they  have  received  benefit  from  his 
treatment,  fearing  that  others  'may  think  they  have  been 
mentally  affected. 


INTRODUCTION  5 

Fees.  What  to  charge  for  his  services  will  occasion  the 
clinical  psychologist  considerable  thought  on  opening  his 
office.  Giving  professional  advice  in  regard  to  maintaining 
or  restoring  mental  action  in  the  case  of  normal  persons  in 
whom  the  physicians  find  no  physical  disturbance  requiring 
a  prescription,  which  is  the  work  of  a  mental  hygiene  ad- 
viser, is  something  new  and  apparently  so  simple  to  the  un- 
initiated that  one  foresees  that  only  a  few  persons  will  ap- 
preciate the  previous  preparation  required  to  carry  on  such 
work  successfully  or  the  fatigue  entailed  by  it.  Moreover, 
a  satisfactory  examination  takes  so  much  time,  usually  an 
hour  and  occasionally  more,  that  one  can  receive  but  a  very 
limited  number  of  consulters  in  a  day. 

After  talking  the  matter  over  with  a  leading  psychiatrist  in 
San  Francisco,  I  finally  decided  to  adopt  his  rates :  Ten  dol- 
lars an  hour  for  the  first  visit  and  five  dollars  for  the  sub- 
sequent ones.  Persons  who  could  not  afford  to  pay  this 
fee  were  given  half  rates,  or  if  this  was  too  great  a  financial 
burden  upon  their  resources,  they  were  treated  free  at  one 
of  the  two  clinics  which  I  had  opened.  It  may  be  of  inter- 
est to  those  wishing  to  know  something  definite  regarding 
the  immediate  returns  from  such  work  to  be  told  that  the 
fees  of  my  private  office  during  the  first  year  amounted  to 
$60  per  month,  and  during  the  second  year  $100  per  month. 
Of  course,  this  does  not  compare  in  any  way  with  the  in- 
come of  a  physician,  but  in  view  of  the  fact  that  there  is 
such  a  decided  increase  in  the  income  during  the  second 
year,  practically  double,  and  as  I  had  been  told  on  all  sides 
that  it  would  be  impossible  for  any  one  to  support  him- 
self, even  partially,  as  a  consulting  psychologist,  I  have 
thought  it  well  to  publish  these  facts.  As  regards  the 
financial  side,  it  is  not  to  be  forgotten  that  I  live  in  a  com- 
munity where  I  have  many  old  acquaintances,  whom  I  have 


6  MENTAL  HYGIENE 

largely  charged  nothing.  Also  that  some  others  who  were 
properly  clinic  consulters  from  the  financial  standpoint,  for 
various  reasons  have  been  treated  free  in  my  privae  office. 
Moreover,  if  I  had  included  the  amount  remaining  unpaid 
on  bills  which  I  expect  to  be  paid  later,  the  income  this 
year  would  have  been  considerably  larger. 

Psychological  versus  medical  terminology.  The  term 
consulter  has  been  substituted  for  the  term  patient,  which 
applies  to  persons  seeking  medical  advice.  This  has  been 
done  with  an  object,  namely,  that  the  person  coming  for 
advice  might  clearly  understand  that  the  person  whom  he 
was  consulting  was  not  a  physician.  If  there  was  any  pos- 
sibility of  his  not  realizing  that  he  was  not  getting  advice 
from  a  physician  in  coming  to  the  mental  hygiene  office,  he 
was  told  this.  The  title  of  doctor  gives  one  a  cer- 
tain prestige ;  however,  and  tis  it  had  been  previously  gen- 
erally used  in  addressing  me,  I  decided  to  allow  the  consul- 
ters to  employ  it  or  not,  as  they  pleased  in  addressing  me, 
but  I  have  been  careful  in  writing  my  name  to  put  Ph.D. 
after  and  not  Dr.  before  it.  In  fact,  everything  possible  has 
been  done  to  give  the  impression  that  I  wished  it  to  be 
clearly  understood  that  I  am  a  psychologist  and  not  a 
physician. 


CHAPTER  ONE 

DISTRIBUTION  AS  TO  SEX,  AGE,  AND  PLACE  OF 

THE  CONSULTATION 

In  Table  I  below,  the  numbers  visiting  the  three  different 
centers  where  I  held  office  hours,  are  segregated.  Work  at 
the  San  Francisco  Polyclinic  was  begun  at  the  time  my 
private  office  was  opened;  that  at  Mount  Zion  Dispensary, 
where  a  large  per  cent,  of  the  consulters  were  Jewish  peo- 
ple, a  year  later.  To  each  of  the  clinics  one  morning  a  week 
and  occasionally  two  have  been  given. 

TABLE    I. 


Age 

Private 
Office 

San  Francisco 
Polyclinic 

Mount  Zion 
Dispensary 

Total 

T.     M.      F. 

T.     M.      F. 

T       M      F. 

T.     M.      F. 

6  Yr«. 

2                 2 

972 

11        6       5 

22     13       9 

7-13 

17      13       4 

48      31      17 

37      27     10 

102      71      31 

14-21 

21       11      10 

21        6      15 

46      34      12 

88      51     37 

22-30 

24      16       8 

27       4      23 

16        1      15 

67      21     46 

31-40 

40      11      29 

42       8      34 

12        3       9 

94      22     72 

41-50 

26       6      20 

39       6      33 

15        5      10 

80     17     63 

51-60 

11        3       8 

12        1       11 

1                 1 

24       4     20 

61-70 

3                3 

2                2 

0 

5                5 

71-84 

2                2 

1        1 

2        1        1 

5                3 

Unclas- 
sified 

0 

826 

5                5 

13       2       11 

Total 

146      60     86 

209      66    143 

145      77      68 

500    203    297 

T.— total  M.— male  F.— female 

The  above  table  shows : 

i.  The  number  of  consulters  at  Mount  Zion  has  been 
greatest.  This  is  not  only  due  to  the  fact  that  other  clinics 
are  larger  there,  but  also,  I  suspect,  from  a  comparison 
with  the  consulters  elsewhere,  to  the  racial  peculiarities  of 


8  MENTAL  HYGIENE 

the  Jewish  people.  Without  going  into  too  great  detail  I 
am  not  able  to  bring  out  these  differences  in  the  table.  In 
the  way  of  illustration  it  may  be  said  that  if  the  table  were 
so  arranged  as  to  show  the  number  of  individuals  belonging 
to  the  same  family  who  were  treated  in  the  Mental  Hygiene 
Clinic,  it  would  be  seen  that  family  group  treatment  has  been 
much  more  necessary  at  Mount  Zion  Dispensary. 

2.  Three-fifths  of  those  visiting  the  mental  hygiene  offices 
are  females,  probably  not  a  greater  proportion,  however, 
than  in  the  case  of  other  clinics. 

3.  After  40  years  of  age  the  number  of  consulters  de- 
creases. 

4.  Up  to  40  the  number  of  consulters  increases  in  the  pri- 
vate office.    In  the  clinic  where  the  influence  of  the  physicians 
and  the  teachers  is  more  potent  as  regards  sending  persons 
to  the  mental  hygiene  adviser,  the  highest  point  as  regards 
number  of  consulters  falls  in  one  case  between  7  and  13 
years  and  in  the  other  between  14  and  21. 

5.  Evidently  31-50  years  of  age  is  the  stress  period  as 
regards  the  need  of  mental  hygiene  aid  among  females. 

6.  Among  males  the  stress  period  is  7-21.     This  can  be 
explained  by  the  fact  that  feeble-mindedness,  insubordination, 
and  adolescent  disturbances  attract  more  attention  in  boys 
than  in  girls. 


CHAPTER  TWO 

THE  MENTAL  AND  PHYSICAL  EXAMINATION  OF 

THE  CONSULTERS. 

Mental  examination.  In  my  private  office  I  took  the  con- 
suiter's  history  myself  on  a  card.  Each  consulter  was  asked 
to  give  a  chronological  account  of  his  life.  He  was  closely 
questioned  wherever  there  seemed  to  be  any  likelihood  of 
getting  more  exact  and  detailed  information.  An  effort  was 
also  made  to  fill  in  apparent  omissions  in  his  recital  by 
questioning.  He  was  asked  about  his  usual  dreams  and 
occasionally  to  keep  a  written  record  of  them.  In  some 
cases  the  history  which  is,  as  far  as  the  consulter's  report 
is  concerned,  introspective  in  nature,  giving  only  an  account 
of  what  is  above  the  threshold  of  consciousness,  was  com- 
pleted through  getting  what  was  below  the  threshold,  by 
applying  psychoanalysis,  by  the  giving  of  the  spontaneous 
arising  ideas  or  the  description  of  spontaneous  arising  visual 
images,  and  occasionally  by  giving  Jung's  association  test. 
I  have  not  used  hypnotism  in  the  last  two  years  for  diag- 
nostic purposes,  but  formerly  I  was  able  through  it  to  get 
diagnostic  information,  in  that  the  person  was  often  not  able 
to  keep  to  himself  certain  things  he  had  not  intended  to  re- 
veal. It  seemed  to  me  in  such  cases  it  was  not  the  particular 
details  which  the  patient  revealed,  for  I  confess  I  do  not 
place  entire  confidence  in  these,  but  as  starting  points  for 
examination  by  other  methods,  the  results  that  I  found 
were  of  value.  The  belief  in  what  is  popularly  called  "the 
subconscious  mind"  is  so  widespread  that  the  consulters  are 
usually  quite  willing  to  have  psychoanalysis  employed.  They 
are  not,  however,  always  well  pleased  when  they  begin  to 
realize  that  the  subconscious  mind  is  probably  merely  the 


If)  MENTAL  HYGIENE 

storehouse  of  forgotten  experiences  which  have  come  to 
them  in  their  previous  life  through  the  senses,  sight,  hear- 
ing, etc.  Occasionally  the  consulter's  automatic  utterances, 
also  talking  to  himself,  revealed  what  was  going  on  in  his 
mind.  This  came  out  in  a  striking  way  in  the  case  of  a 
delinquent  feeble-minded  boy  whose  unconscious  remarks 
betrayed  his  delinquencies  along  sexual  Lines.  Once  01 
twice  a  consulter's  automatic  writing  has  given  a  cue  as  to 
his  mental  condition.  I  have  found  the  automatic  writing 
method  in  cases  where  there  is  an  attention  disturbance,  very 
useful.  This  once  came  out  in  the  case  of  a  Stanford  Univer- 
sity student  on  the  margin  of  whose  English  theme  and  occa- 
sionally in  the  body  of  the  paper,  the  name  of  a  famous  foot- 
ball man  was  repeatedly  written.  During  the  examination  any 
mistake  in  acting,  reading,  writing  and  in  forgetting  words, 
as  well  as  any  physical  manifestations  of  psychological  inter- 
est, were  of  course  recorded.  Mental  tests  were  also  fre- 
quently given,  not  only  to  determine  whether  the  person  was 
feeble-minded,  but  also  to  get  material  that  might  be  useful 
in  a  diagnostic  way. 

In  the  clinic  the  blank  given  in  the  appendix  was  used  in 
taking  a  child's  history  and  one  similar  to  it  with  an  adult. 
It  will  be  seen  that  these  blanks  encourage  a  searching  ex- 
amination of  the  consulter's  life,  without  which  it  is  impos- 
sible of  course  to  deal  adequately  with  a  case.  The  history 
blank  was  filled  in  by  a  social  worker  trained  to  do  this 
work.  In  some  cases  a  life  chart  was  later  constructed  from 
the  history  to  bring  out  in  relief  the  origin  and  source  of  a 
mental  disturbance,  as  for  example,  some  delinquency. 
Where  the  consulter's  deportment  during  the  taking  of  the 
history  or  later  suggested  feeblemindedness  or  when  it 
seemed  desirable  to  get  more  definite  information  in  re- 


DISTRIBUTION  OF  SEX  AND  AGE  II 

gard  to  his  mental  calibre  or  when  the  person  had  come  for 
vocational  advice  and  placement,  a  mental  test  was  also  made 
by  the  social  worker. 

When  the  history  and  test  making  was  completed,  the 
social  worker  brought  the  data  into  my  office  and  the  points 
that  were  to  act  in  a  suggestive  way  in  my  own  examination 
of  the  case  were  noted.  The  patient  was  then  shown  in. 
After  a  provisional  diagnosis  had  been  made,  such  thera- 
peutic treatment  as  was  possible  in  view  of  the  examination 
already  made,  was  given  and  a  date  set  for  the  consulter's 
return  to  the  mental  hygiene  clinic  for  further  advice  and 
examination.  The  social  worker  who  was  to  look  after  the 
case  was  then  called  in  and  arrangements  made  for  her 
visits  to  the  consulter's  home.  Such  visits  are  indispensable 
in  that  they  allow  opportunity  for  modifying,  supplementing 
and  emphasizing  the  treatment  given  at  the  first  visit.  Even 
if  no  modification  of  treatment  seems  necessary,  there  is 
still  a  good  reason  for  frequent  visits  to  the  clinic.  The 
director  through  acting  as  an  audience  is  a  strong  stimulus 
to  the  complete  and  persistent  carrying  out  on  the  part  of 
the  consulter  of  my  psychotherapeutic  treatment  given. 

One  of  the  many  problems  confronting  one  in  regard  to 
re-education  work  is  how  to  give  advice  effectively.  Experi- 
ence shows  that  straightforward  modes  of  attack  are  de- 
sirable. The  consulters  feel  the  need  of  guidance  in  their 
activities.  A  crisp  and  business  like  way,  so  as  not  to  convey 
the  impression  that  it  is  merely  a  friendly  talk  without  prac- 
tical significance,  is  usually  most  efficacious.  As  regards 
making  an  impression  upon  the  consulter,  the  mental  hygiene 
adviser  must  have  that  cooperation  and  help  of  the  social 
worker  which  comes  ^rom  his  really  believing  in  the  effective- 
ness of  the  methods  tmployed  and  therefore  in  the  import- 
ance of  getting  the  patient  back  to  the  clinic  at  frequent 
intervals,  to  receive  further  advice. 


12  MENTAL  HYGIENE 

Physical  examination.  The  consulters  were  closely 
questioned  as  to  their  physical  condition  and  even  if  there 
were  no  complaints  along  this  line  they  were  in  general  re- 
quired to  take  a  complete  medical  examination.  In  no  sense 
was  a  physical  examination  made  in  the  mental  hygiene 
office,  though  the  eyes  and  ears  and  speech  organs  were 
sometimes  tested  in  a  very  casual  way  by  the  social  worker 
to  determine  whether  the  consulter  ought  to  be  sent  to  the 
eye,  ear,  nose,  throat  or  dental  clinics,  as  well  as  to  the 
medical.  The  posture,  gait,  and  feet  were  also  observed  by 
us  both  to  ascertain  whether  an  orthopedic  examination  was 
desirable.  If  anything  in  the  consulter's  deportment  sug- 
gested the  need  of  psychoneurological  examination  he  was 
also  sent  to  that  clinic  after  I  had  examined  the  reflexes  in 
a  casual  way  for  the  purpose  of  getting,  if  possible,  further 
data  that  might  confirm  the  provisional  judgment  that  such 
examination  ought  to  be  made  by  a  neurologist.  If  any  of 
the  physicians  thought  immediate  treatment  was  desirable, 
the  consulters  were  urged  and  in  some  cases  compelled  to 
take  it,  if  they  wished  to  continue  to  come  to  the  mental 
hygiene  clinic.  As  a  matter  of  fact,  nearly  every  con- 
suiter  has  been  sent  to  one  or  more  different  medical  special- 
ists and  I  very  much  doubt  whether  many  other  clinicians 
have  sent  as  many  people  to  physicians  as  I  have  during  the 
past  two  years.  To  attempt  to  give  proper  mental  hygiene 
advice  until  one  has  a  clear  picture  of  the  person's  physical 
conditions  seems  to  me,  folly.  Of  course,  physical  treatment 
often  improves  the  mental  condition  and  vice  versa.  The 
large  number  of  persons  referred  to  me  by  physicians,  even 
while  they  were  still  treating  the  cases  themselves,  shows 
that  many  of  them  also  think  so.  The  question  may  be  asked 
whether  the  consulting  psychologist  has  a  work  to  do  with 
the  individual  which  is  independent  of  that  of  the  physician. 


DISTRIBUTION  OF  SEX  AND  AGE  13 

If  one  will  look  over  the  mental  disturbances  enumerated  in 
Table  II  he  will  see  that  the  medical  profession  has  made 
no  provision  for  dealing  with  a  large  number  of  them.  In 
fact,  it  is  a  question  whether  many  physicians  would  care  to 
handle  such  cases.  At  any  rate  they  have  referred  a  number 
of  them  to  me  for  treatment.  In  view  of  my  experience  I 
am  convinced  that  the  work  of  the  clinical  psychologist  not 
alone  supplements  that  of  the  medical  profession  in  many 
cases,  but  also  is  entirely  outside  of  it  in  some  cases. 


Cibranj  of 

Hubert  Jlauhnn   *laH 


CHAPTER 

CLASSIFICATION    OF   THE   MENTAL   DISTURB- 

ANCES OF  THE  CONSULTERS  AND  SUMMARY 

OF  THE  GENERAL  MANNER  OF  HAN- 

DLING THE  VARIOUS  CLASSES 

The  consulters  have  been  classified  in  Table  II  below  so 
as  to  show  the  mental  disturbances  which  brought  them  to 
the  mental  hygiene  office.  Such  a  classification  is  more  or 
less  arbitrary.  As  for  example,  in  placing  the  delinquents  in 
one  class,  some  of  the  subnormal  children  had  to  be  taken 
from  class  9,  and  again  most  cases  of  syphilis  referred  to 
the  mental  hygiene  clinic  by  physicains  were  not  put  in 
class  2  but  in  class  12.  That  is  to  say,  the  consulters  were 
classified  under  that  disturbance  which  for  various  reasons 
appeared  best  to  describe  the  kind  of  mental  action  which 
brought  them  to  the  clinic. 

1.  Cases    of    true    and    incipient    forms    of    insanity. 
The  guardians  of  those  consulters  who  could  not  be  kept 
at  home  were  informed  as  to  the  institution  to  which  they 
should  be  sent  and  the  proper  procedure  to  follow  in  order 
to  get  them  into  it.    Other  cases  were  referred  to  a  neuro- 
psychiatrist.    In  the  incipient  cases,  with  the  consent  of  the 
attending  physician,  re-education  or  some  similar  therapeu- 
tic method  was  undertaken  if  it  seemed  probable  that  it 
would  be  beneficial. 

2.  Cases  of  nervous  disease,  neuritis,  chorea,  syphilis, 
tabes,  shell  shock,  etc.     These  cases  were  also  sent  to  a 
psychoneurologist.     If  it  appeared  that  anything  could  be 
done  in  a  psychotherapeutic  way  in  arresting  the  disease  or 
in  ameliorating  the  present  condition,  or  in  hardening  the 
person  against  future  attacks,  the  mental  hygiene  adviser 

14 


L  0\ 


TABLE  II. 


CASES  OF 

Private  Office 

San  Francisco 
Polyclinic 

ll 

N| 

•—  ^     V 

So 

-3 

1 

1     True   or    incipient   forms   of   insanity  —  demen- 

tia  praecox    (6),   paranoia  and   paranoid  pecu- 

liarities   (1),   manic  depressive  psychoses    (5), 

hysteria     (4),    epilepsy     (4),    or    psychopathic 

states    (16). 

16 

13 

7 

36 

2     Nervous   diseases:  —  Neuritis    (1),  chorea    (3), 

syphilis  (2).  tabes  (1),  shell  shock  (1),  etc. 

1 

3 

4 

8 

3     Borderline  states  :  —  Neurasthenia  and  extreme 

lassitude     (25),    psychastenia     (phobias,    etc.) 

(12). 

19 

14 

37 

4     Sensory  disturbances  accompanied  by  those  that 

are  mental:  —  of  the  eye   (1),  the  ear   (3),  the 

mouth  or  nose  and  throat   (speech  difficulties) 

(8). 

3 

3 

12 

5     Unhealthy   post-operative  mental   condition. 

1 

1 

6     Habit  pains,  feelings  of  suffocation,  etc.,  partly 

at  least  having  a  mental  basis. 

2 

2 

7     Alcoholism. 

1 

3 

4 

8     Supernormality. 

3 

3 

9     Supernormality    exclusive   of    delinquency    (in- 

cluding feetole-minded,  borderline,  and  dull  per- 

sons)   and  of  school  retardation  for  other  rea- 

sons than  low  mentality. 

15 

34 

14 

63 

10     Juvenile    delinquency     (truancy,     insubordina- 

tion,   fighting,    lying,    pilfering,    stealing,    etc. 
(50),  and  cases  disciplinary  in  character  (36). 

7 

21 

58 

86 

11     Mental  disturbances  connected  with  the  adoles- 

cent, menopause,  senile,  'and  pre^senile  periods 

of  life. 

11 

18 

2 

31 

12     Mental  disturbances  where  "nervousness,"  "de- 

pression,"   or    in    common    parlance    an    "un- 

strung" condition  is  present. 

16 

64 

19 

99 

13     Insomnia. 

14     Lack     of    emotional     control     (anger,     hatred. 

1 

2 

Jealousy,    and    other    unhealthy    emotions    pre- 

dominating). 

4 

5 

3 

12 

15     Marked  weakness  of  will   (1),  inability  to  hold 

attention,  loss  of  memory,  or  prevalence  of  im- 

ages having;  an  hallucinatory  character   (2). 

1 

1 

1 

3 

16     Failure  in  adjustment  of  family  and  community 

life. 

25 

5 

30 

17     Women  needing  advice  as  to  parental  or  infant 

care. 

2 

2 

4 

18     Persons  desiring  advice  as  to  the  most  effec- 

T 

tive    methods    to    employ    in    "improving    and 

strengthening  their  minds." 

11 

19     Persons  desiring  advice  along  the  lines  of  vo- 

11 

cational  selection,  training  and  placement. 

7 

4 

4 

15 

20     Unclassified  mental  disturbances. 

17 

24 

41 

146 

121 

143 

500 

l6  MENTAL  HYGIENE 

gave  advice  along  the  lines  of  avoiding  fatigue  and  too  great 
physical  and  mental  stimulation,  and  if  it  was  a  clinic  case, 
concerning  the  social  service  work  to  be  undertaken.  The 
social  workers  did  what  they  could  to  carry  out  any  sug- 
gestions given  by  other  clinics  as  well  as  ours.  As  for  ex- 
ample, in  a  case  diagnosed  by  the  physician  as  tabes  dorsalis, 
the  shoes  recommended  were  provided,  exercises  advised 
were  arranged  for,  arrangements  made  with  a  charitable 
organization  for  proper  food,  and  appropriate  work  obtained. 

3.  Cases  of  borderline  states: — neurasthenia,  and  ex- 
treme lassitude,  psych  asthenia,  (phobias,  etc.)  In  these 
cases  overwork,  very  protracted  periods  of  persistent  work, 
and  uneconomical  ways  of  doing  work  played  a  prominent 
role.  Often  the  condition  could  be  explained  also  by  some 
of  the  causes  enumerated  under  classes  u  and  15. 

Some  of  the  consulters  with  difficulties  having  a  neuras- 
thenic coloring  had  well  marked  phobias.  These  were  of 
two  kinds.  A  general  undifferentiated  feeling  of  fear  or  a 
fear  of  some  particular  thing.  There  were  in  the  second 
case  certain  places  that  may  be  termed  "fear  arousing  cen- 
ters." The  Oakland  ferry  is  one  of  these  and  a  particular 
street  car  line  another.  The  growing  up  of  the  fear  complex  is 
slow  and  not  always  easy  to  trace.  One  of  the  common  fear 
instigators  is  gas  in  the  stomach.  The  person  had  come 
gradually  to  associate  with  it  some  heart  disturbance  fears, 
as  that  he  may  faint  in  the  street  or  be  unable  to  get  back  to 
his  house.  The  result  was  that  he  finally  became  unwilling 
to  leave  it.  Such  fears  are  enhanced  by  unusual  fatigue  and 
frequently  by  the  fact  that  the  person  rarely  goes  into  unac- 
customed places,  and  fails  to  get  the  new  ideas  which  would 
crowd  out  the  old  painful  ones  which  have  become  enor- 
mously strong  through  constant  attention  and  repetition 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  17 

The  problem  of  course  in  such  cases  is  through  psychothe- 
rapy to  supplant  the  injurious  and  fear  producing  thoughts 
by  more  healthy  ones.  When  such  fears  are  accompanied 
by  visual  or  strong  auditory  images  or  inner  speech,  such 
images  can  often  be  replaced  through  appropriate  exercises 
and  if  this  is  impossible,  they  can  be  broken  up  or  modified  or 
associated  so  that  they  will  lose  their  former  fear  arousing 
charcater.  My  own  method  has  been  where  such  fears  exist, 
as  they  are  more  common  when  one  has  no  pressing  work 
on  hand,  to  get  the  person  to  undertake  some  entirely  new 
line  of  work,  and  as  I  have  found  that  they  are  often  present 
when  one  is  weary,  short  and  frequent  rest  periods  are  in- 
troduced into  their  daily  regime.  The  treatment  of  persistent 
ideas  is  particularly  difficult  and  it  seems  to  me  requires 
more  prolonged  effort  than  almost  any  other  mental  diffi- 
culties which  I  have  attempted  to  treat.  Phobias  are  also  very 
much  more  common  than  I  had  supposed.  I  confess  I  have  a 
theory  that  some  artificial  aid,  say  a  phonograph  constantly 
repeating  certain  appropriate  sentences,  could  be  made  very 
useful  in  a  suggestive  way  along  this  line.  It  may  sound 
absurd  but  I  suspect  the  phonograph  method,  if  I  may 
be  allowed  to  so  term  it,  has  great  possibilities  as  regards 
the  replacing  of  unhealthy  ideas  by  healthy  ones. 

4.  Cases  of  sensory  disturbances  accompanied  by  those 
that  are  mental.  The  person  was  referred  for  examination 
to  the  proper  specialist  in  such  cases  for  physical  treatment ; 
but  where,  for  example,  as  was  sometimes  the  case,  lack 
of  attention  played  a  decided  role  in  the  trouble  or  some 
complex  lay  at  its  base,  the  treatment  was  also  taken  up  in 
the  mental  hygiene  clinic.  In  the  case  of  speech  disturb- 
ances where  the  physical  examination  showed  no  need  of 
medical  treatment,  psychological  treatment  along  re-educa- 


jg  MENTAL  HYGIENE 

tional  lines  was  given  while  the  trainer  who  made  speech 
defects  a  specialty  and  to  whom  the  person  had  been  re- 
ferred did  his  work. 

5.  Cases  of  unhealthy  post-operative  mental  condition. 

With  the  one  consulter  here  classified  everything  possible  was 
done  to  arouse  him  to  the  necessity  of  carrying  out  the  ex- 
ercises prescribed  by  the  physician.  With  cases  classified 
elsewhere  some  of  the  various  occupations  now  used  by  the 
reconstruction  aids  in  occupational  therapy  in  army  hospitals 
were  employed. 

6.  Cases  of  habit  pains,  feeling  of  suffocation,  etc., 
partly  at  least  having  a  mental  basis.     Treatment  by  sug- 
gestion was  often  used  in  such  cases,  also  exercises  to  direct 
the  attention  to  other  parts  of  the  body. 

7.  Cases  of  alcoholism.     A  number  of  persons  who  were 
taking  too  much  alcohol  came  to  the  office  for  some  mental 
difficulty  as,  for  example,  frequent  auditory  hallucinations. 
In  all  the  cases  where  the  alcoholic  drinking  was  serious, 
the  fundamental  cause  of  it  was  in  no  two  cases  the  same. 
It  grew  in  one  case  out  of  the  momentary  relief  it  allowed 
from  mental  conflicts  with  which  the  consulter  could  not 
cope ;  in  another  from  a  failure  in  adjustment  in  daily  life ; 
in  another  from  extreme  fatigue  and  discouragement  re- 
sulting from  it ;  in  another  from  pleasure  in  a  world  of 
fancy  which  the  consulter  was  not  able  to  create  without  a 
stimulant ;  in  another  from  imitation  of  intemperate  asso- 
ciates and  suggestions  received  from  them.     I  have  placed 
but  four  persons  in  the  alcoholic  class  because  only  in  these 
cases  was  it  thought  that  the  taking  of  alcohol  was  the  pri- 
mary cause  of  the  mental  trouble.    The  mental  disturbances 
of  the  other  alcoholic  persons,  as  was  said,  have  been  clas- 
sified under  other  divisions.    Alcoholic  drinking,  for  example, 
in  the  case  of  a  person  who  had  had  a  phobia,  while  doubt- 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  1Q 

less  increasing  the  fear-difficulty,  had  apparently  been  in- 
dulged in  subsequently  as  regards  the  phobia  and  as  a  means 
of  escaping  from  the  suffering  entailed  by  it. 

8.  Cases  of  super-normality.     These  were  gifted  chil- 
dren who  were  inattentive  or  disorderly  in  school,  for  the 
most  part  because  insufficient  or  uninteresting  tasks  were 
being  assigned  to  them,  or  they  became  much  interested  in 
some  particular  thing  as  airships,  or  wireless  telegraphy, 
about  which  they  spent  most  of  their  time  in  building  air 
castles. 

9.  Cases  of  subnormality  exclusive  of  delinquency  and 
of  school  retardation  for  other  reasons  than  low  mentality. 
Such  consulters  were  examined  by  the  Stanford  Revision  of 
the  Binet-Simon  or  the  Yerkes-Bridges  tests.    If  these  tests 
indicated  feeble-mindedness,  farther  examination  was  made 
on  the  points  suggested  by  Fernald — physical  examination, 
family  history,  personal  and  developmental  history,  school 
progress,  examination  in  school  work,  practical  knowledge 
and  general  information,  social  history  and  reaction,  econ- 
omic history  and  reactions,  economic  efficiency,  moral  reac- 
tions, mental  examination — before  passing  on  the  mental 
status  of  the  individual.     Such  additional  examination  re- 
quired of  course  much  social  service  work.     If  the  con- 
suiter  was  found  to  be  feeble-minded,  his  parent  or  guardian 
was  directed  as  to  his  placement  in  a  special  school;  and 
explicit  directions  were  given  as  to  home  training.     The 
feeble-minded  person  was  not  left  here,  but  his  name  was 
put  in  a  card  catalogue  looking  to  future  official  registration 
and  perhaps  sterilization. 

Many  children  who  were  suspected  of  being  feeble- 
minded were  sent  by  their  teachers  to  the  office  or  their 
parents  brought  them  on  account  of  their  poor  work  or  in- 
ability to  do  certain  things  which  children  of  their  age  can 


2O  MENTAL  HYGIENE 

usually  do.  When  it  was  found  through  examination  that 
they  were  approximately  normal  their  special  difficulties  were 
looked  into.  In  many  cases  it  was  not  difficult  to  find  the 
cause.  Certain  children,  for  example,  who  were  doing  par- 
ticularly poor  work  in  language  work,  came  from  families 
of  foreigners  where  no  English  was  spoken  in  the  home; 
again  it  was  found  that  some  children  who  were  unable  to 
take  care  of  themselves  properly,  as  to  wash  and  dress 
themselves,  had  always  had  these  things  done  for  them.  In 
the  case  of  several  children  who  wore  laced  shoes  the  in- 
ability to  tie  a  bow  knot  in  the  Binet- Simon  tests  gave  a 
hint  of  the  lack  of  home  training  which  lay  at  the  root  of 
the  school  trouble. 

1 0.  Cases  of  juvenile  delinquency  and  those  disciplin- 
ary in  character.  The  large  number  of  such  cases  grew  out 
of  the  fact  that  the  principal  of  the  Ethan  Allen  School,  a 
school  to  which  boys  guilty  of  such  delinquencies  as  insub- 
ordination, truancy,  fighting,  lying,  pilfering,  stealing,  etc., 
were  sent  from  the  various  schools  of  the  city,  asked  the 
Mount  Zion  Dispensary  to  allow  her  to  send  her  pupils  there 
for  examination  and  treatment.  It  was  decided  to  give  all  of 
these  children  a  group  test  in  their  own  school  before  this 
was  done.  Mr.  Herbert  E.  Knollin,  who  had  had  much  ex- 
perience with  Dr.  Terman  in  mental  testing,  assisted  me  in 
this  work.  The  army  tests  were  used  with  50  of  the  older 
pupils.  Fig.  i  below,  gives  the  per  cent,  of  the  feeble- 
minded, etc.,  boys  in  the  school.  It  will  be  seen  that  28% 
of  these  boys  were  feeble-minded  when  classified  by  the 
Stanford  Revision  of  the  Binet-Simon  tests.  The  remain- 
ing 50  boys  who  were  not  sufficiently  advanced  to  use  the 
army  tests  were  given  the  curtailed  form  of  the  Binet- 
Simon  tests  proposed  by  Doll.  According  to  these  test? 
50%  were  feeble-minded. 


CLASSIFICATION  OF  MENTAL  DISTURBANCES 


21 


Army 

teete 


Figure  1.  Distribution  of  "intelligence  of  the 
pupils  of  the  Ethan  Allen  School  according 
to  the  army  tests  in  terms  of  the  Terraan 
classification,  and  the  brief  Binet-Simon 
(Doll)  tests.  Areas,  left  to  right  repre- 
sent percentages  of  feeble-minded,  dull- 
normal,  and  average  normal,  respectively. 

4  * 

Distribution  of  Intelligence 


Thirty-five  of  the  boys  whom  the  group  and  Doll  tests 
given  at  the  school  had  shown  to  be  feeble-minded  or 
borderline  cases  were  given  the  Stanford  Revision  of  the 
Binet-Simon  tests  at  the  mental  hygiene  clinic  in  Mount  Zion 
Dispensary  and  wherever  there  was  any  physical  weakness 
suspected,  they  were  sent  to  other  clinics.  The  result  of  the 
individual  mental  tests  correlated  well  with  these  of  the 
group  tests.  The  teachers  in  the  Ethan  Allen  School  were 
evidently  greatly  surprised  to  find  so  many  of  their  boys 
subnormal.  Had  they  previously  examined  their  record 
books  for  each  child  they  would  have  seen  that  not  a  child  in 
the  school  is  up  to  the  proper  grade,  4%  are  6-8  yrs.,  29% 
are  4-5  years.,  50%  are  2-3.9  yrs->  and  17%  are  1-1.9  yrs-  be- 
hind their  grade. 


22  MENTAI,  HYGIENE 

Not  only  the  scholarship  of  these  boys  but  their  slovenly 
appearance,  their  posture,  and  their  movements  indicate  that 
many  of  them  belong  to  an  inferior  type.  In  view  of  the 
data  on  the  mental  status  of  the  boys,  the  principal  was  told 
that  many  of  the  methods  employed  in  training  backward  and 
feeble-minded  children  ought  to  be  introduced  into  her  school 
— also  that  in  view  of  what  we  know  today  regarding  the  in- 
fluence on  the  child's  mental  development  of  proper  posture 
and  good  coordination  of  movement,  greater  stress  should 
be  laid  on  those  matters  and  that  no  better  single  exercise 
could  be  given  than  teaching  the  boys  to  "stand  at  atten- 
tion" on  occasions  when  it  was  proper  to  do  so. 

The  handicap  under  which  some  of  these  delinquent  boys 
are  working  is  also  seen  in  the  clinical  reports  on  their  phy- 
sical examination.  Under  nourishment,  "flat  feet" — shod 
with  ill-fitting  shoes,  adenoids,  diseased  tonsils,  defective 
eyes  with  imperfectly  adjusted  glasses,  pains  in  the  stomach 
produced  by  eating  indigestible  food,  etc.,  are  reported.  The 
value  of  a  personal  mental  and  physical  examination  in  deal- 
ing with  such  boys  can  be  illustrated  from  the  study  of  a 
boy  who  was  recently  sent  to  the  mental  hygiene  clinic  for 
advice  as  to  his  being  allowed  to  go  to  work,  which  he  was 
very  anxious  to  do  on  account  of  straightened  family  cir- 
cumstances. It  was  stated  that  his  school  work  was  very 
poor  and  that  he  was  not  interested  in  it.  Examination 
showed  that  his  vision  was  defective  and  that  glasses  would 
not  correct  it,  and  that  he  had  a  "weak  heart."  A  work  per- 
mit was  advised  on  condition  that  light  work  should  be 
selected  that  would  eventually  lead  to  the  advancement  that 
was  possible  in  the  case  of  a  boy  of  his  mentality. 

The  straightened  financial  condition  of  their  families  and 
their  difficulty  in  mastering  even  simple  intellectual  work 
make  most  of  these  boys  long  to  go  to  work  and  strongly 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  23 

supports  the  principal's  desire  that  some  of  them  be  allowed 
to  work  half  a  day  (for  which  they  are  paid)  and  attend 
school  the  other  half  day.  Such  a  plan  would  introduce  the 
boys  into  the  industrial  world  under  proper  supervision.  Of 
course  at  the  termination  of  the  school  age,  most  of  them 
could  be  left  to  shift  for  themselves.  There  are,  however, 
some  feeble-minded  boys  in  that  school  that  should  be  per- 
manently registered  and  more  or  less  supervised.  I  wish  the 
Board  of  Education  of  San  Francisco  might  initiate  perma- 
nent registration  of  feeble-minded  children.  Where  they 
are  not  put  under  custodial  care  they  ought  to  be  safe- 
guarded to  the  extent  of  registration.  It  ought  to  be  ar- 
ranged ultimately  that  at  least  those  children  showing 
strong  sex  tendencies  should  also  be  sterilized  for  the  pro- 
tection of  the  next  generation. 

From  a  social  service  point  of  view  the  Ethan  Allen 
School  is  very  interesting.  Through  visiting  the  homes  one 
gets  a  much  more  correct  and  complete  idea  of  the  cause 
of  their  delinquency  and  the  intensive  and  very  personal 
care  that  alone  will  save  them.  The  social  work  shows  that 
the  stealing,  lying,  fighting,  sex  delinquencies,  have  often 
a  heredity  basis  of  alcoholism,  feeble-mindedness,  epilepsy, 
insanity,  etc.  Social  heredity  is  found  to  play  a  highly  im- 
portant role  in  these  delinquencies.  The  stealing  (fruit, 
junk,  etc.)  of  which  they  are  guilty  was  often  not  frowned 
upon  by  their  families.  Racial  and  family  peculiarities  and 
customs  explain  the  cause  of  the  delinquencies,  especially  the 
stealing  by  many  of  these  boys  and  suggests  that  if  the  boys 
are  to  be  entirely  reformed  forces  must  be  set  to  work  to 
train  the  parents.  A  large  per  cent,  of  these  delinquent  boys 
are  Italians,  one-third  of  them  live  in  the  Italian  quarter,  a 
very  restricted  area  of  the  city,  where  the  close  proximity 
with  each  other  would  naturally  emphasize  racial  character- 


24  MENTAL  HYGIENE 

istics.  Nearly  50%  of  these  Italian  children  the  tests  showed 
to  be  feeble-minded.  The  fruit  stealing,  which  is  often  the 
beginning  of  the  stealing  of  other  things,  is  encouraged  by 
the  custom  of  the  neighborhood.  Observation  showed  that 
the  children  of  this  district  are  sent  to  the  markets  early  in 
the  morning  with  a  bag  to  collect  the  discarded  fruit — the 
bag  gradually  coming  to  be  used  to  collect  fruit  not  dis- 
carded. This  is  a  danger  locality  for  the  delinquent  boy 
and  a  properly  trained  policeman  could  do  o  good  work  here. 
The  fighting  so  common  among  these  boys  and  so  much 
complained  of  is  often  a  defensive  measure.  They  have  not 
the  intelligence  to  meet  the  word  attacks  of  the  brighter 
children,  and  to  ward  these  off  they  use  the  only  weapon  at 
their  command — the  fist.  Some  of  their  lying  is  due  doubt- 
less to  imperfect  powers  of  observation  and  weak  memory 
and  to  the  desire  to  play  an  important  role.  Their  truancy 
sometimes  comes  from  lack  of  interest  in  their  work,  growing 
in  some  cases  out  of  their  inability  to  hear  and  see.  A  lively 
imagination  which  had  its  material  from  some  of  the  moving 
pictures  they  had  seen,  led  to  some  of  their  stealing  and 
other  escapades.  It  probably  even  instigated  some  of  their 
sex  misdemeanors.  This  was  revealed  by  the  content  of  the 
automatic  talking  of  one  boy  as  he  sat  waiting  to  be  brought 
into  the  mental  hygiene  clinic.  Abnormal  sex  delinquencies 
are  also  the  result  of  the  close  family  life,  the  ill  fitting  cloth- 
ing, the  information  imparted  by  evil  companions  of  the 
neighborhood,  and  the  lack  of  proper  attention  to  cleanliness 
and  bodily  needs.  I  have  gone  into  the  more  intimate  life 
of  these  boys  to  give  an  idea  of  what  was  attempted  in  a 
social  service  way  in  dealing  with  this  and  other  classes  of 
consulters. 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  2$ 

The  reasons  for  sending  children  for  correction  and  dis- 
cipline to  the  mental  hygiene  office  are  numerous.  One  of 
these  is  masturbation.  Its  removal  was  often  accomplished 
through  impressing  the  parents  with  the  importance  of 
cleanliness  and  changing  the  child's  sleeping  place, — some- 
times by  having  a  doll  or  something  similar  taken  to  bed  to 
direct  the  attention  away  from  a  dangerous  field.  The  work 
of  child  correction  was  not  only  largely  a  psychical  matter, 
as  in  overcoming  a  slovenly  way  of  speaking,  but  often  a 
matter  of  training  him  in  proper  physical  habits  as  to  keep 
the  mouth  shut  after  adenoids  have  been  removed. 

Children  were  often  brought  to  the  clinic  for  pilfering 
which  had  its  origin  in  their  taking  money  from  the  father's 
pockets.  Sometimes  it  came  from  the  desire  for  something 
the  child  ought  to  have  had.  One  boy  told  me  about  steal- 
ing money  to  get  a  pair  of  skates  which  his  mother  would 
not  get  because  she  was  afraid  he  would  fall  and  hurt 
himself. 

In  regard  to  the  children  sent  for  correction  and  disci- 
pline it  may  be  said  that  in  trying  to  overcome  a  child's 
fault,  the  important  thing  is  to  speak  in  such  a  way  that  he 
will  remember  what  has  been  said  to  him.  To  do  this  the 
mental  hygiene  adviser  must  recall  experimental  work  upon 
the  memory  and  employ  the  shortest  and  most  effective  meth- 
od of  permanently  fixing  an  idea  in  the  child's  mind.  Another 
task  in  child  corrective  work  is  in  instructing  the  parent  and 
occasionally  even  the  teacher  to  give  suitable  rewards  and 
punishments.  Few  people  seem  to  realize  that  different 
kinds  of  punishment  are  not  good  or  bad  in  themselves  but 
in  proportion  to  their  being  beneficial  in  the  case  of  the 
particular  child.  To  deprive  a  child  of  candy  who  does 
not  care  for  it  is  a  non-effective  mode  of  discipline.  In 


26  MENTAL  HYGIENE 

short,  my  experience  is  that  the  child's  likes  and  dislikes 
should  determine  the  kind  of  punishment  given  him.  There 
are  in  the  case  of  the  animal  two  incentives  that  are  used  in 
controlling- — reward  and  punishment.  These  are  what  are 
to  be  used  in  controlling  and  developing  proper  habits  in 
children.  While  a  child's  physical  likes  and  dislikes,  as  for 
certain  foods,  etc.,  may  sometimes  be  appealed  to  advan- 
tageously, of  course  one  appeals  to  higher  mental  activities 
when  possible.  The  kind  of  punishment  to  be  adopted  de- 
pends, as  was  said,  upon  the  child's  preferences.  Practically 
successful  government  depends  on  the  one  hand  on  giving 
the  child  what  he  likes  and  on  the  other  in  depriving  him  of 
what  he  likes.  Isolation  may  be  good  for  some  children. 
Whether  it  is  to  be  in  the  dark  or  not  depends  upon  its 
arousing  fear  of  the  dark.  Putting  to  bed  may  be  very  good 
for  a  child  as  an  aid  to  removing  the  fatigue  which  gives  rise 
to  the  irritability  and  quarreling,  but  considering  the  wide 
prevalence  of  masturbation  among  children,  it  will  be  a  kind 
of  punishment  that  one  will  be  somewhat  chary  of  giving, 
even  in  the  case  of  a  nervous  child  needing  rest.  Whipping  a 
child  may  be  very  useful  in  some  cases,  but  one  sees  fre- 
quently in  the  mental  hygiene  clinic  the  bad  effect  on  a 
child's  movements  of  sudden  slaps.  Whatever  mode 
of  punishment  is  adopted  it  is  very  important  that  some 
means  of  getting  prompt  obedience  from  the  child  be  em- 
ployed, for  I  have  found  that  the  inattention  so  often  com- 
plained of  by  the  teacher  can  usually  be  traced  to  lax 
home  discipline.  We  can,  through  applying  what 
we  know  today,  of  the  conditioned  reflex,  improve  our 
modes  of  punishment.  In  fact  all  punishment  is  more  or 
less  based  upon  it.  In  telling  a  child  what  he  must  not 
again  do,  he  is  sometimes  whipped,  with  the  idea  that 
whipping  can  be  finally  abandoned  and  the  word  alone  or 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  27 

the  given  situation  bring  about  the  desired  response.  What 
punishment  we  shall  combine  with  the  word  and  the  situa- 
tion in  order  that  it  shall  gradually  be  able  to  accomplish  its 
purpose,  depends,  as  was  just  said,  upon  various  considera- 
tions. Judging  from  older  consulters  where  liking  and  dis- 
liking are  too  often  the  motivation  principles,  I  should  say 
that  a  sense  of  duty  as  a  mainspring  of  action  needs  to  be 
more  frequently  employed  with  children. 

At  present  the  psychological  offices  connected  with  the 
schools  are  largely  for  diagnostic  purposes,  that  is,  are 
clearing  houses.  The  work  with  all  these  children  has 
shown  me  that  the  scope  of  the  work  in  such  offices  should 
be  greatly  enlarged.  In  fact  they  should  be  turned  into 
mental  hygiene  clinics  where  the  individual  child  who  is 
doing  unsatisfactory  work  in  school  or  is  delinquent,  can 
be  carefully  studied  and  treated  in  order  that  his  impedi- 
ments to  right  action  may  be  overcome  or  he  may  be  placed 
where  they  will  not  injure  others. 

1  1 .  Cases  of  mental  disturbances  connected  with  the 
adolescent,  menapause,  senile  and  pre-senile  periods  of 
life.  Much  greater  information  is  needed  by  people  in 
general  regarding  each  of  these  periods,  in  order  that  the 
pains  accompanying  the  physical  and  mental  disturbances 
incident  to  them  may  be  endured  with  more  equanimity. 
Some  of  the  mental  disturbances  grow  out  of  the  fact  that 
persons  especially  in  the  last  two  periods  feel  that  they  are 
entering  upon  an  unfamiliar  and  not  altogether  desirable 
time  of  life.  The  adolescent  constantly  complains  of  feel- 
ing "so  strange"  as  regards  life  about  him  and  the  older 
personal  worries  over  his  lost  youth.  Unfortunately  the  com- 
munity in  a  suggestive  way  helps  to  strengthen  these  and 
allied  ideas,  by  its  attitude.  The  grown  up  boy  for  ex- 
ample is  treated  as  a  child  by  his  family,  and  the  vital  ques- 


28  MENTAL  HYGIENE 

tions  concerning  the  problems  of  life  which  fill  his  mind  at 
this  time  are  treated  lightly  or  are  altogether  ignored.  In 
the  case  of  the  old  person  the  daughter  gradually  takes 
upon  herself  the  mother's  work  in  the  house.  On  the  street 
she  grasps  her  arm  firmly  and  guides  her  steps  as  she 
would  those  of  a  child  and  almost  lifts  her  into  the  street 
car.  The  task  of  the  mental  hygiene  adviser  is  to  give  all 
such  consulters  an  adequate  philosophy  of  life  and  to  as- 
sist them  in  making  any  adjustments  necessary  to  the 
period  on  which  they  are  entering;  also  in  the  case  of  the 
older  persons,  to  help  them  to  understand  that  loss  of 
memory  and  intellectual  power  is  due  more  to  indolence  and 
laziness  than  to  the  fact  that  they  are  "growing  old."  It  is 
the  last  two  periods  that  need  especially  to  be  more  care- 
fully studied.  Some  few  do  become  insane  doubtless  from 
the  neglect  of  those  around  them  during  the  adolescent 
period,  but  the  waste  in  the  community  of  "growing  old"  too 
young  is  immensely  greater.  When  looked  at  from  all  sides  it 
is  appalling.  Oh !  that  the  community  would  come  to  realize 
how  very  monotonous  a  world  with  only  young  people  in  ii 
would  be  and  that  the  writer  was  not  entirely  wrong  who 
said  that  youth  was  given  to  people  to  make  them  endurable 
until  they  were  old. 

1 2.  Cases  of  mental  disturbances  where  "nervousness," 
"depression,"  "excitability,"  or  in  common  parlance  an 
"unstrung"  condition  is  present.  The  trouble  lying  at  the 
base  of  the  physical  and  mental  condition  indicated  by 
"nervousness,"  etc.,  is  extremely  individual.  It  may  be 
largely  physical  as  the  result  of  an  operation  or  overwork, 
or  due  to  an  uneconomical  use  of  time  and  force  which 
results  in  an  inability  to  accomplish  one's  work,  or  to  an 
irritation  and  impatience  as  regards  others,  or  to  some  phy- 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  2Q 

sical  deformity,  or  to  an  influence  of  a  tyrannical  old  or 
a  young  person  who  insist  on  imposing-  his  ideas  and  habit? 
on  his  relatives  and  friends,  or  to  an  unsteadiness  of  pur- 
pose, or  to  hurry  growing  out  of  the  fact  that  one  has  not 
the  ability  to  accomplish  the  amount  of  work  desired  or 
demanded,  or  to  the  dissatisfaction  with  life  which  results 
from  having  no  set  goal  toward  which  one  is  steadily  direct- 
ing his  course,  or  to  sexual  irregularities,  or  to  dissatisfac- 
tion as  regards  the  sexual  life,  or  to  difficulties  having  to  do 
with  the  domestic  relations,  or  to  timidity,  or  to  placing 
work  emphasis  on  the  wrong  place,  or  to  lack  of  interest  in 
one's  present  occupation,  or  to  having  nothing  definite  to  do, 
or  to  doubt  as  to  what  to  undertake,  etc.,  etc.  In  cases  of 
this  class  it  takes  much  time  to  find  out  the  cause  of  the 
trouble  and  when  it  is  found,  to  remove  it,  because  of  the 
fact  that  it  means  the  person  must  often  establish  entirely 
new  habits  of  thought  and  action. 

I  found  so  many  cases  where  the  consulters  were  helped  by 
a  program  that  I  keep  the  blank  (shown  below  in  reduced 
form)  on  hand  to  use  for  this  purpose. 

This  blank  is  filled  in  with  the  patient  and  then  given 
him  to  follow  out  and  put  +  where  he  had  followed  the 
program,  and — where  he  has  not.  The  completed  program 
he  brings  back  at  his  next  visit  and  it  is  discussed  with  him. 
Often  this  treatment  alone  removed  the  "nervous"  and 
"confused"  feeling  of  which  he  had  complained  at  his  first 
visit.  Where  a  person's  nervousness  was  due  to  a  variety 
of  uncontrolled  factors  in  his  daily  life,  I  have  occasionally 
set  him  to  work  to  try  to  help  some  member  of  his  own 
family,  or  a  relative,  or  friend  suffering  from  a  similar  dif- 
ficulty. A  mother,  for  example,  who  was  given  Barker's 
"Principles  of  mental  hygiene  applied  to  the  management  of 
children  predisposed  to  nervousness"  to  read  with  a  view 
to  rooting  out  certain  of  her  own  nervous  peculiarities  which 


MENTAL  HYGIENE 


Name, 


Address, 


7-  8 

Mon. 

Tues. 

Wed. 

Thurs. 

Fri. 

Sat. 

Sun. 

8-  9 

9-10 

10-11 

11-12 

12-  1 

1-  2 

2-  3 

3-  4 

4-  5 

5-  6 

Even 

were  very  noticeable  in  the  child,  improved  her  own  "nerv- 
ousness," as  well  as  that  of  her  child. 

13.  Cases  of  insomnia.  Many  of  the  consulters  of  the 
previous  class  also  complain  of  loss  of  sleep  but  there  were 
two  cases  where  this  was  the  sole  trouble.  A  fear  that  in- 
sanity would  result  from  it  doubtless  increased  the  difficulty 
in  their  cases.  The  methods  which  had  been  recommended 
by  their  kind  friends  as  sleep-producing,  such  as  counting 
the  number  of  sheep  jumping  over  a  fence,  etc.,  had  but  in- 
creased their  wakefulness  and  fears.  Another  method  was 
employed  by  the  mental  hygiene  clinic.  As  people  often 


CLASSIFICATION  OF  MENTAL  DISTURBANCES  3! 

sleep  more  hours  than  they  suppose  they  sleep,  the  chart 
below  was  given  to  be  filled  out  for  a  week : 

NAME, 


Date 

Hour  of 
Going  to  Bed 

Hour  of 
Getting  Up 

No.  of  Hours 
of  Sleep 

Dreams 

When  the  consulters  found,  as  they  usually  did,  that  they 
were  sleeping  many  more  hours  than  they  had  supposed  the 
fears  vanished  and  they  soon  acquired  again  the  normal 
number  of  sleep  hours. 

14.  Cases  of  lack  of  emotional  control,  (anger,  ha- 
tred, jealousy,  and  other  unhealthy  emotions  predomi- 
nating.) Emotion  is  so  often  the  mainspring  of  action  that 
the  problem  set  to  the  mental  hygiene  adviser  in  dealing  with 
persons  who  give  way  to  unhealthy  feelings  is  therefore 
largely  one  of  substituting  healthy  emotions  which  may 
serve  as  an  impetus  to  action  or  of  transferring  the  main- 
spring of  action  to  a  healthy  intellectual  field.  It  often 
means  the  upbuilding  of  a  new  world  on  the  part  of  the 
consulter  and  is,  therefore,  a  matter  of  much  time  and  ef- 
fort. In  such  development  I  have  found  the  keeping  of  the 
emotion  chart,  to  be  discussed  later,  very  useful.  It  aroused 
the  consulter  to  make  a  continuous  effort  and  thus  aided  in 
quickening  the  formation  of  a  new  emotional  habit. 


32  MENTAL  HYGIENE 

15.  Cases  of  marked   weakness  of  will,   inability  to 
hold  the  attention,  loss  of  memory,  prevalence  of  images 
having  an  hallucinatory  character  brought  three  to  the 
mental  hygiene  office.    These  cases  and  those  classified  else- 
where could  be  given  to  illustrate  mental  difficulties  dis- 
cussed by  Ribot  in  his  works  on  diseases  of  the  will,  atten- 
tion, etc.    One  of  the  most  striking  of  the  three  cases  classi- 
fied here  is  that  of  a  woman,  sane  in  all  other  respects,  who 
stands  every  day  several  hours  before  the  washstand  in  her 
bathroom  washing  herself  and  crying  because  she  cannot 
stop  doing  it.    A  study  of  the  case  showed  that  the  removel 
of  duties  through  the  growing  up  of  her  children,  the  ac- 
quisition of  wealth,  and  a  natural  love  of  ease,  played  an  im- 
portant part  as  causal  factors. 

1 6.  Cases  of  failure  in  adjustment  of  family  and  com- 
munity life.     Such  persons  came  because  they  were  suffi- 
ciently intelligent  to  realize  their  social  maladjustment  and 
their  lack  of  knowledge  and  will  as  regards  coping  satisfac- 
torily not  only  with  their   personal  but  also  their  group 
problems,  such  as  getting  on  comfortably  with  their  husbands 
or  wives  and  interfering  relatives  and  friends ;  carrying  on 
their  homes  or  their  business  successfully ;  helping  their  ac- 
quaintances and  friends  in  solving  their  problems ;  in  short, 
getting  a  better  grip  on  the  affairs  of  their  daily  life.    This 
class  of  cases  makes  a  greater  demand  upon  one's  life  experi- 
ence than  any  other.     To  deal  properly  with  the  questions 
brought  for  solution  one  is  soon  made  aware  that  he  needs 
to  have  lived  many  years  and  to  have  had  many  and  varied 
experiences. 

1  7.  Cases  of  women  desiring  advice  as  to  pre-natal 
and  infant  care.  These  four  persons  came  because  they  and 
their  husbands  felt  that  they  must  have  mental  help  to  pre- 


CLASSIFICATION  09  MENTAL  DISTURBANCES  33 

pare  themselves  for  the  mental  training  of  the  coming 
child.  In  the  present  year's  work  directed  to  the  saving  of 
the  child  one  is  astonished  when  one  recalls  the  health- 
giving  power  of  properly  developing  feeling  and  thinking 
from  birth,  to  find  that  a  child's  mental  development  is  al- 
most completely  ignored  in  the  books  dealing  with  such 
work.  Matters  of  vital  interest,  such  as  the  unhealthy  and 
narrowing  and  incapacitating  effect  of  impressing  only  par- 
ental ideals  upon  the  child,  the  danger  to  which  an  only 
child  is  exposed  and  the  unhealthy  coxplexes  that  are  formed 
in  the  very  earliest  years,  are  passed  over  far  too  lightly. 
Where  the  women  have  come  for  pre-natal  advice  they  have 
been  directed  along  these  lines  as  well  as  in  regard  to  their 
own  mental  health. 

18.  Cases  of  persons  desiring  advice  as  to  the  most 
effective  methods  to  employ  in  "improving  and  strength- 
ening their  minds."  As  to  the  method  to  be  used  in  stength- 
ening  of  the  memory,  if  that  was  the  direction  in  which  the 
consulter  felt  he  was  weak,  one  must,  of  couse,  consider  the 
cause.  For  example,  it  was  found  that  memory  was  often 
weak  in  the  direction  in  which  one  did  not  wish  to  remem- 
ber. One  lady  had  formed  the  habit  of  forgetting  engage- 
ments that  she  did  not  care  for  some  reason  to  keep.  Here 
the  forgetfulness  had  a  protective  character  in  quieting  the 
forgetter's  conscience  as  regards  her  duty  in  meeting  the 
engagement.  Forgetting  due  to  this  cause  extends  in  some 
cases  to  so  many  fields  that  the  improving  of  the  memory  is 
a  question  of  transforming  the  character.  Again,  loss  of 
memory  was  sometimes  due  to  an  exaggerated  subjective  or 
objective  tendency.  In  one  of  the  state  insane  hospitals  at  a 
staff  meeting  of  the  physicians  not  long  ago  I  saw  two  men 
who  showed  in  a  marked  degree  what  I  have  often  seen  in  a 
small  degree  in  many  of  the  consulters.  One  of  them  could 


34  MENTAL  HYGIENE 

remember  with  great  detail  all  of  the  experiences  of  his 
personal  life,  but  matters  of  larger  interest,  such  as  the  ex- 
istence of  the  war  in  Europe,  had  been  entirely  forgotten. 
The  other  man  could  recall  nothing  of  his  personal  life  but 
knew  well  what  had  taken  place  in  a  political  way  in  recent 
years.  Cases  of  this  kind  are  very  suggestive  from  an  edu- 
cational standpoint.  They  show  that  the  subjective  child 
should  be  trained  to  look  outward  and  the  objective  child 
inward.  Again,  want  of  interest  was  the  cause  of  a  poor 
memory  in  certain  directions.  Such  persons  resembled  the 
boy  who  forgot  to  feed  the  chickens  and  bring  in  the  wood 
and  could  not  remember  his  school  work,  but  was  able  to 
give  a  very  full  account  of  the  plot  of  several  moving  pictures 
he  had  seen.  The  fact  that  what  had  been  learned  had  not 
been  learned  in  a  way  to  insure  its  ready  reproduction  was 
another  cause  of  poor  memory.  When  the  cause  of  the  poor 
memory  had  been  ascertained,  the  psychological  exercises  to 
be  mentioned  later  were  often  used  with  good  results  to 
strengthen  it. 

In  some  of  these  cases  the  consulters  complained  of  weak- 
ness of  attention.  An  assistant  cashier  in  this  city  used  psy- 
chological exercises  for  many  months  to  develop  concen- 
tration of  attention.  Diffused  attention  had  been  required 
for  his  previous  work,  but  for  his  new  work  as  assistant 
cashier,  concentrated  attention  was  needed.  Some  of  the  at- 
tention exercises  that  he  used  were  very  simple,  as  the  trac- 
ing of  the  figure  eight  mentally,  but  they  were  very  effective 
in  accomplishing  the  desired  end. 

1 9.  Cases  of  persons  desiring  advice  along  the  line  of 
vocational  selection,  training  and  placement.  The  total 
number  15  given  in  Table  II  does  not  really  represent  the 
number  of  such  cases.  Many  of  these  placed  in  class  II,  for 
example,  might  have  been  placed  here,  for  their  condition 


CLASSIFICATION  0*  MENTAL  DISTURBANCES  35 

was  sometimes  due  to  their  failure  in  the  vocation  selected 
and  their  recovery  was  brought  about  by  applying  work 
therapy.  In  the  placement  of  some  of  the  cases  the  cooper- 
ation of  one  of  the  employment  bureaus  of  the  city  was  se- 
cured. The  consulter  was  sent  to  this  bureau  after  a  study 
had  been  made  in  the  mental  hygiene  clinic  as  to  his  occu- 
pational liking  and  ability  and  the  opportunities  in  the  com- 
munity for  him  to  carry  out  his  desires.  The  consulter's  his- 
tory was  taken  in  the  mental  hygiene  clinic  as  to  the  time  and 
place  of  his  birth,  his  present  residence,  his  school  record,  his 
previous  and  present  occupation  and  wages,  and  the  result 
of  the  physical  and  medical  examination.  He  was  then  given 
a  short  mental  test  after  which  a  card  was  made  out  for  him 
to  present  at  the  employment  office.  On  this  card  was  sum- 
marized the  result  of  the  consulter's  mental  and  physical  ex- 
amination, (whether  he  had  finished  primary,  grammar,  high 
school,  university  or  technical  school)  and  his  experience 
(misfit,  untrained,  experienced,  trained).  In  view  of  all 
these  things,  including  his  character  as  shown  by  his  pre- 
vious life  and  his  general  appearance  and  manner,  an  opinion 
was  also  expressed  regarding  the  particular  kind  of  work 
that  the  applicant  could  probably  do  with  success.  The 
mode  of  procedure  proved  very  satisfactory. 

20.  Cases  of  unclassified  mental  disturbances. 
In  some  of  these  cases  there  was  no  one  set  of  difficulties 
that  predominated  sufficiently  for  classification.  In  others  on 
account  of  limited  time  or  for  other  reason  no  diagnosis  had 
been  made. 


CHAPTER  FOUR 

THE    PSYCHODIAGNOSTIC   AND   THERAPEUTIC 
MODES  OF  TREATMENT  EMPLOYED 

The  methods  used  by  the  mental  hygiene  adviser  fall  into 
two  classes :  those  having  a  psychiatrical  origin  and  those 
based  on  principles  laid  down  in  general  psychology  and  on 
experiences  gained  in  psychological  laboratory  work.  Again, 
all  the  methods  used  depend  to  some  extent  upon  the  time  at 
one's  disposal  Introspection  is  so  foreign  to  the  daily  think- 
ing of  many  peoj*!?  and  requires  so  much  training  before  it 
can  be  done  advantageously,  that  psychoanalysis  is  a  time- 
absorbing  method  and  more  particularly  suited  to  private 
office  work.  It  is  therefore  necessary  to  modify  it  some- 
what when  one  uses  it  in  the  clinic.  On  the  other  hand  sug- 
gestion can  be  applied  in  so  short  a  period  of  time  that  it 
is  better  adapted  to  the  clinic  if  one  considers  the  time  ele- 
ment alone. 

The  History.  Occasionally  it  happens  that  the  examina- 
tion of  what  is  above  the  threshold  of-  consciousness  through 
introspection — that  is,  through  looking  into  one's  own  mind 
as  one  does  in  reporting  to  the  person  who  takes  the  his- 
tory, not  only  often  reveals  sufficient  material  for  a  satis- 
factory diagnosis  and  therapeutic  attack,  but  also  for  the  re- 
adjusting and  fitting  of  the  consulter  to  his  environment,  and 
for  restoring  and  adjusting  the  misfits.  This  was  true  in  the 
case  of  a  woman  in  a  state  of  opposition  to  her  husband  who 
was  earning  $150  per  month,  while  he  earned  but  $125,  and 
insisted  on  depositing  her  salary  check  in  a  bank  to  his  own 
credit  and  doling  out  money  to  her  in  sums,  in  some  cases 
not  exceeding  ten  cents.  No  deeper  psychological  examina- 

36 


MODES  Of  TREATMENT  EMPLOYED  37 

tion  was  needed  for  a  psychotherapeutic  attack.  In  a  thera- 
peutic way  the  history-taking  itself  acts  therapeutically 
through  relieving  the  mind  of  the  heavy  burden  that  it 
has  been  compelled  previously  to  bear  alone.  This  was  the 
case  with  two  young  men  whose  fears  and  worries  imme- 
diately vanished  on  unburdening  their  minds  in  giving  their 
histories.  Also  of  two  German  women  who  unburdened 
their  hearts  in  the  clinic,  telling  how  worried  they  were 
about  their  families  in  Germany  from  whom  they  had  not 
heard  since  we  entered  the  war,  and  who  for  fear  of  being 
considered  pro-German  had  not  dared  to  mention  such 
worries,  and  had  become  ill  largely  through  suppressed 
grief. 

The  examination  of  what  is  under  the  threshold  of  con- 
sciousness through  the  use  of  psychoanalysis  sometimes  acts 
in  a  similar  way.  The  mental  disturbances  of  a  young 
woman  due  to  irregularities  of  conduct  in  which  seduction 
had  played  a  part,  immediately  disappeared  on  being  treated 
by  the  methods  of  psychoanalysis.  Many  of  the  consulters 
take  kindly  to  psychoanalytical  examination.  They  call  it 
the  examination  of  their  "sub-conscious  mind."  Before  such 
examination  is  made  it  is  carefully  explained  to  them  that 
what  is  termed  the  "sub-conscious  mind"  refers  merely  to 
that  what  we  have  learned  through  the  senses  is  more 
or  less  perfectly  preserved  under  the  threshold  of 
consciousness.  They  are  told  that  careful  experi- 
mentation even  in  physical  research  has  not  yet 
shown  that  there  is  anything  in  the  sub-conscious  except 
what  was  put  there  originally  through  the  ordinary  use  of 
the  senses  and  that  speaking  figuratively  the  mind  is  merely 
the  storehouse  of  experiences  which  have  come  to  us  in  our 
previous  life  through  seeing,  hearing,  etc.  That  this  "sub- 
conscious mind"  is  in  a  dynamic  and  not  entirely  in  a  static 


38  MENTAL  HYGIENE 

condition,  and  that  therefore  the  elements  of  an  experience 
sometimes  re-arrange  themselves  and  that  this  explains,  for 
example,  why  he  has  an  image  of  an  acquaintance  dressed  as 
he  has  not  previously  seen  him  or  of  the  face  of  a  man  he 
does  not  recognize.  The  condensation,  symbolization,  sub- 
limation, etc.,  in  the  material  brought  to  the  surface  of  con- 
sciousness, while  it  makes  interpretation  extremely  difficult, 
is  an  advantage  often,  in  that  the  patient  could  otherwise 
not  be  induced  to  acknowledge  the  emotionally  colored  com- 
plexes that  come  to  consciousness  if  he  fully  realized  he 
was  betraying  something  for  which  he  was  directly  respon- 
sible. Later  when  his  confidence  is  gained  and  he  under- 
stands that  the  elements  probably  have  a  fact  basis,  he  often 
becomes  interested  in  arranging  them  in  the  original  com- 
plexes. 

In  investigating  what  is  under  the  threshold  of  conscious- 
ness sometimes  Freud's  method  was  used ;  that  is,  the  con- 
suiter  was  given  a  comfortable  semi-reclining  chair,  told  to 
close  his  eyes  and  talk  out  everything  that  came  into  his 
mind;  and  sometimes  when  the  consulter  has  spontaneous 
visual  or  auditory  images  the  visual  image  method  was 
used;  that  is,  the  method  where  the  consulter  after  having 
had  explained  to  him  what  visual  and  auditory  images 
are,  closed  his  eyes  and  described  the  images  that 
spontaneously  arose.  The  image  method  has  a  more 
objective  character  and  is  more  easily  described,  and 
in  carrying  out  the  instructions  the  consulter  does  not  feel 
responsible  for  the  content  and  has  not  therefore  the  temp- 
tation to  conceal  what  arises  in  his  mind.  The  image  method 
is  useful  often  from  the  fact  that  it  gives  one  the  mental 
material  in  the  form  in  which  it  is  disturbing  the  consulter. 
One  can  then  set  to  work  at  once  to  break  up  the  trouble- 


MODES  OF  TREATMENT  EMPLOYED  39 

some  images  or  to  replace  them  by  healthy  static  or  move 
ment  images.  In  using  the  method  of  psychoanalysis  and  the 
image  method  his  wrongly  executed  acts  and  mistakes  in 
speaking,  reading,  and  writing,  and  his  forgetting  of  par- 
ticular words  were  carefully  studied,  also  any  words  or 
melodies  that  haunted  his  mind.  The  study  of  the  consulter's 
dreams  was  particularly  illuminating.  It  did  not  occur  to  a 
woman,  for  example,  who  told  of  seeing  herself  in  animated 
conversation  with  a  man  and  on  awaking  felt  a  glow  of 
pleasure,  that  she  was  giving  a  clew  to  her  present  nervous 
trouble  which  began  in  connection  with  falling  in  love  with 
another  man  after  her  marriage. 

It  is,  it  seems  to  me,  with  children  that  the  diagnostic 
value  of  dreams  is  greatest.  Questioning  a  child  as  to  what 
he  thinks  about  elicits  but  a  monosyllabic  response,  but  when 
asked  as  to  what  he  dreamed  about  last  night  and  the  night 
before,  he  gives  an  enthusiastic  account  of  the  airship  or 
something  else  he  saw.  His  inattentive,  dreamy  expression 
as  he  looks  out  of  the  windows  in  the  schoolroom  is  ex- 
plained. It  is  not  alone  that  dreams  betray  the  thoughts 
that  are  interfering  with  the  child's  work,  but  they  often  give 
one  a  hint  not  alone  of  the  child's,  but  of  the  adult's  normal 
preferences  and  aspirations  and  of  the  character  of  the  cen- 
sor that  was  stifling  and  paralyzing  natural  inclination.  We 
know  from  psychological  work  in  the  laboratory  that  dreams 
can  be  transformed  and  modified.  I  have  often  asked  myself 
in  listening  to  a  consulter's  dreams  whether  it  was  not  pos- 
sible to  make  therapeutic  use  of  such  experiments,  especially 
in  banishing  the  dreams  that  are  accompanied  by  trembling 
and  other  accompaniments  of  fear. 

Suggestion  and  hypnotism.  Strictly  speaking  I  have  not 
used  hypnotism,  that  is,  put  a  consulter  in  a  complete  hyp- 
notic state  during  the  last  two  years,  though  I  had  used  it 


4O  MENTAL  HYGIENE 

previously  a  great  deal  for  experimental  purposes.  I  have 
often  employed  suggestion  for  temporary  purposes  and  oc- 
casionally, though  rarely,  I  have  brought  on  a  condition 
resembling  the  hypnoidal  state.  As  many  of  the  consulters 
find  it  hard  to  relax  I  precede  the  giving  of  the  particular 
suggestion  by  a  suggestion  to  bring  about  a  relaxed  physical 
condition.  The  suggestion  for  psychotherapeutic  purposes 
I  usually  give  as  an  accomplished  fact,  "your  head  does  not 
ache,"  or  "you  do  not  feel  resentment  towards  your  hus- 
band;" while  the  suggestion  for  relaxation  is  given  as  an 
instruction,  that  is,  in  a  way  better  suited  to  getting  the 
consulter  to  take  part  himself  in  bringing  about  the  condi- 
tion, as  "let  your  right  leg  relax."  In  connection  with  re- 
laxation, where  it  is  possible  to  do  it  effectively,  I  sometimes 
teach  the  consulter  to  help  by  auto-suggestion,  that  is,  to 
say  for  example,  "my  right  leg  is  relaxed,"  or  to  use  some 
other  expression  that  will  help  in  bringing  about  an  unin- 
hibited muscular  condition.  I  have  found  suggestion  use- 
ful in  various  ways,  as  in  producing  rest  and  sleep,  removing 
physical  and  mental  pain,  giving  a  motive  for  undertaking 
and  continuing  a  desirable  course  of  action,  etc.  I  have 
occasionally  used  it  as  a  long  distance  remedy.  Through  it 
I  have  been  able,  by  using  the  telephone  to  remove  a  con- 
suiter's  pain  and  to  bring  about  a  calmer  condition  at  a 
distance  of  two  hundred  and  fifty  miles.  Taken  all  in  all, 
however,  I  regard  suggestion  only  as  a  method  to  be  used  in 
emergencies,  until  other  slower,  but  in  the  long  run  more 
effective  methods  can  be  used.  It  is  usually  temporary  in  its 
effects  and  must  be  frequently  renewed.  This  makes  it 
time  consuming,  but  even  where  it  is  not,  it  tends  to  weaken 
the  consulter.  He  should  be  a  partner  in  his  healing;  that 
is,  his  recovery  should  be  effected  through  the  education  of 


MODES  OP  TREATMENT  EMPLOYED  4* 

his  own  thought  and  will.  It  is  for  this  reason  that  the 
method  of  persuasion,  which  as  some  one  says  knocks  at  the 
front  door,  and  does  not,  like  suggestion,  enter  by  the  back 
stairs,  has  been  preferably  used.  All  things  considered, 
persuasion  seems  to  me  the  most  satisfactory  psychotherapeu- 
tic  method  and  for  that  reason  I  have  substituted  it  for  sug- 
gestion wherever  possible.  Psychoanalysis  and  suggestion 
are  favorite  methods  with  consulters.  They  enjoy  the  free- 
dom from  responsibility  that  exists  in  connection  with  this 
method.  One  man  came  not  long  ago  and  asked  me  to  give 
him  psychoanalytical  treatment.  It  required  no  great  amount 
of  probing  below  the  threshold  to  get  at  his  difficulty  which 
had  a  sexual  origin  of  an  abnormal  nature.  When  re-educa- 
tion was  suggested  he  was  aghast.  He  was  unwilling  to 
make  the  effort  required  to  substitute  for  the  hurtful  and 
incapacitating  .thoughts  constantly  lurking  in  *his  mind 
those  that  were  ennobling  and  power  giving.  His  motive 
to  action  was  his  liking  to  do  things.  In  his  case  and  that 
of  many  others  I  have  come  to  see  that  in  the  Puritan  days  of 
duty  as  a  motivation  principle  the  persuasion  and  education 
therapy  would  have  been  more  acceptable  to  the  consulter. 

The  automatic  writing  method.  I  have  occasionally  used 
it.  It  threw  light  on  the  case  of  the  college  girl,  for  ex- 
ample, who  had  written  quite  unconsciously,  the  name  of  a 
baseball  hero  all  over  a  theme  handed  in.  The  automatic 
speaking  method  has,  like  the  automatic  writing  method,  but 
a  limited  use.  We  used  it  quite  unintentionally  on  one 
occasion.  Our  attention  was  attracted  by  the  whispered 
words  of  a  feeble-minded  boy  awaiting  his  turn  in  the 
clinic.  Through  listening  we  got  information  in  regard  to 
his  activities  along  sexual  lines  which  enabled  us  to  show 
that  he  must  no  longer  be  allowed  to  roam  the  streets  alone. 


42  MENTAL  HYGIENE 

Environment  therapy.  By  this  is  not  alone  meant  the 
change  of  scene,  getting  away  from  irritating  centers,  by 
which  one  frees  himself  from  painful  and  monotonous  asso- 
ciations, but  also  the  bringing  in  of  new  surroundings 
where  imitation  can  have  an  opportunity  to  act  in  a  health- 
restoring  way.  I  see  more  and  more  in  dealing  with  de- 
linquent boys  and  learning  where  they  originally  got  some 
of  their  ideas  that  resulted  in  delinquency,  that  we  do  not 
realize  fully  the  possibilities  of  the  moving  picture  as  a 
convenient  method  of  bringing  environment  therapy  to  bear. 

Occupation  and  work  therapy.  Besides  those  just  men- 
tioned other  methods  have  been  used,  as  the  occupation 
method  for  rehabilitation  purposes ;  that  is,  encouraging  the 
consulter  to  knit,  weave,  etc.,  at  first,  and  later,  when  he  had 
sufficiently  recovered,  to  undertake  some  serious  remunera- 
tive work.  Of  course  in  occupational  therapy  the  kind  of 
work  given  is  important  since  each  kind  of  employment  has 
an  intellectual  influence.  Liking  is  not,  however,  the  only 
factor  to  be  considered.  Knitting,  for  example,  is  quieting 
in  its  effect  and  is  generally  liked,  but  it  frequently  allows 
too  much  opportunity  for  a  given  rnind  to  surrender  itself 
to  unhealthy  imaginings.  Work  therapy  was  found  useful 
in  many  different  ways.  It  not  only  removes  anxiety  by 
enabling  the  consulter  to  meet  the  financial  obligations  that 
were  harassing  him,  but  it  also  took  the  attention  and  interest 
away  from  the  field  that  gave  rise  to  the  mental  disturbance. 
It  developed  accuracy  and  breadth  of  thought  and  expression 
and  controlled  the  emotional  absorption,  so  often  present. 
Enforced  work  therapy  may  seem  drastic  in  some  cases,  but 
the  fact  is  that  it  is  often  the  only  kind  of  psychotherapy 
available.  A  man  who  was  reported  by  the  medical  clinic 
as  able  to  take  up  his  life  again  was  sent  to  the  mental 
hygiene  clinic.  He  had  all  sorts  of  excuses  showing  he  was 


MODES  OP  TREATMENT  EMPLOYED  43 

unable  to  work, — among  others  the  need  of  frequent  urina- 
tion. Investigation  showed  that  he  gathered  and  sold  junk. 
The  time  of  year  he  came  to  the  clinic  was  unfavorable  for 
his  business.  While  he  was  waiting  for  the  spring  cleaning 
he  came  to  Mount  Zion  Dispensary  and  got  not  alone  medical 
treatment  but  doubtless  financial  help  from  a  charitable  or- 
ganization associated  with  it.  When  this  last  was  with- 
drawn at  my  suggestion,  he  took  up  work  and  no  longer 
needed  or  sought  advice  in  regard  to  his  health. 

Amusement  therapy  is  far  more  needed,  especially  by 
young  working  women,  than  many  people  realize.  I  have  had 
several  cases  where  the  consulter  gradually  recovered  under 
this  mode  of  treatment  alone. 

Isolation  therapy  is  at  present  too  little  used.  Experience 
with  the  consulter  showed  that  going  "into  retreat,"  the 
keeping  of  a  "quiet  hour,"  has  a  very  beneficial  effect  on 
the  health. 

Physical  exercises  may  be  used  as  a  psychotherapeutic 
method.  I  have  employed  modifications  of  the  "setting  up 
exercises,"  "the  brain  drills,"  etc.,  to  arouse  thought  and  to 
increase  quickness  and  accuracy  in  thinking.  In  limbering  up 
the  mind  and  body  so  that  voluntary  effort  (which  is  partly, 
probably  often,  a  matter  of  muscle — the  overcoming  of  one's 
physical  inertia)  would  be  easier. 

Music  therapy  has  been  used  with  good  effect  in  several 
cases.  Naturally  the  extent  to  which  any  of  the  above 
methods  is  applied  depends  upon  the  mental  make-up  of 
the  consulter  and  the  time  at  one's  disposal  in  applying 
treatment.  My  experience  during  the  last  two  years  in 
working  in  mental  hygiene  has  brought  me  to  feel  that 
re-education  is  the  method  par  excellence  and  it  is  for  this 
reason  that  I  devote  the  next  chapter  to  its  application. 


CHAPTER 

THE  METHOD  OF  RE-EDUCATION 

In  psychotherapeutic  re-educational  work  the  principles 
laid  down  in  general  psychology  must  be  the  guide.  If  after 
getting  well  started  in  mental  hygiene  one  will  but  re-read 
any  modern  work  on  psychology,  he  will  scarcely  find  a  page 
from  which  he  cannot  get  valuable  therapeutic  hints.  In 
psychotherapy  treatment  one  must  not  be  content,  however, 
with  merely  giving  advice  based  on  well  established  psy- 
chological principles,  but  must  give  the  consulter  something 
to  do,  something  that  will  make  him  an  active  participator 
in  bringing  about  his  cure ;  appropriate  psychological  exer- 
cises must  be  prescribed.  On  examining  my  own  psychologi- 
cal laboratory  work  (see  appendix  for  the  bibliography) 
to  see  if  there  was  anything  that  could  be  used  as  mental 
hygiene  exercises,  I  discovered  that  nearly  every  one  of  the 
investigations,  except  No.  4,  contained  something  that  could 
be  employed  in  helping  the  consulter  to  be  a  party  in  his 
treatment.  This  led  to  a  similar  re-examination  of  the  in- 
vestigations of  others  and  I  found  that  what  was  true  of 
mine,  was  also  true  of  theirs.  Below  I  summarize  and  dis- 
cuss some  of  the  exercises  which  have  been  given  with  good 
effect.  While  as  yet  I  have  gone  but  a  step  with  this  kind 
of  treatment,  it  is  far  enough  to  convince  me  that  it  works 
beneficially.  I  am  inclined  to  think  that  what  gives  the 
tinct  from  that  of  the  physician  on  the  other  hand,  and  the 
psychologist  a  place  in  the  psychotherapy  today,  entirely  dis- 
social worker  on  the  other,  is  not  alone  his  large  knowledge 
of  psychological  principles,  but  also  his  years  of  experience  in 
carrying  on  work  in  the  psychological  laboratory.  Such 
knowledge  enables  one  to  penetrate  into  the  human  mind, 


44 


METHOD  OF  RE-EDUCATION  45 

which  the  time  needed  for  the  required  training  in  their  own 
special  fields  of  work  makes  it  impossible  for  the  members 
of  the  other  two  professions  to  acquire.  The  consulting 
psychologist  will  of  course  have  this  in  common  with  the 
physician  and  social  worker,  namely,  that  his  usefulness  will 
also  depend  much  upon  the  amount  of  general  knowledge 
and  experience  stored  away.  As  I  am  not  attempting  to 
write  a  book  on  clinical  psychology,  I  pass  over,  without  any 
attempt  to  enumerate  them,  the  very  large  number  of  psy- 
chological principles  which  underlie  psychotherapeutic  treat- 
ment. As  the  transforming  of  psychological  experimental 
work  into  therapeutic  exercises  has  not  been  previously 
taken  up,  I  enumerate  and  discuss  below  some  of  the  ex- 
ercises for: 

1.  Acquiring  emotional  control; 

2.  Strengthening   physical    and   psychical   hardening   and 
endurance; 

3.  Increasing,    correcting,   and   controlling  sensation   and 
perception; 

4.  Doing  away  with  thought  confusion  and  the  attendant 
ineffective  action; 

5.  Enlarging  and  controlling  conscious  and  sub-conscious 
mental  activity ; 

6.  Modifying  and  banishing  persistent  unhealthy  images 
and  ideas; 

7.  Increasing  accuracy  and  rapidity  in  thinking, — banish- 
ing mental  laziness ; 

8.  Increasing,    strengthening,    and    controlling    attention, 
memory,  and  imagination; 

9.  Eliminating  bad  habits  and  establishing  good  ones ; 

10.  Increasing  accuracy  and  rapidity  of  movements  and 
eliminating  involuntary  abnormal  positions  and  move- 
ments (tics)  ; 


46  MENTAL  HYGIENE 

11.  Bringing    about    muscular    relaxation    and    removing 
fatigue ; 

12.  Increasing  through  practice  the  ability  to  do  mental  and 
physical  work; 

13.  Correcting  and  restoring  mental  and  physical  activities 
through  the  use  of  imitation; 

14.  Developing  a   dignified  posture   which   would  help   in 
bringing  about  courage  and  composure; 

15.  Increasing  physical,  and  through  it  mental  lightness; 

1 6.  Improving  speech; 

17.  Establishing  a  healthy  motivation  principle. 

18.  Restoring  and  creating  normal  physical  functioning; 

19.  Establishing  normal  social  and  moral  activities  and  parti- 

cipation; 

20.  Building  up  a  sane  and  healthy  philosophy  of  living. 

i  k  In  helping  the  consulter  in  the  acquiring  of  emotional 
control  I  frequently  use  a  chart,  suggested  by  a  temperature 
chart,  which  I  call  an  emotion  chart.  In  Fig.  2  below  an 
emotion  chart  that  has  been  filled  out  by  a  consulter  suffering 
from  depression  is  reproduced. 


Figure  Z. 


The  object  of  this  chart  is  to  trace  the  effect  of  the  exercise 
given  on  the  emotional  condition.  A  dot  placed  on  the  base 
line  ab  always  shows  that  at  that  time  (the  numbers  on  the 
chart  indicate  the  particular  hours  of  the  day)  the  con- 
suiter  was  in  an  indifferent  state  emotionally.  A  dot  placed 


METHOD  OF  RE-EDUCATION  47 

below  this  line  indicates  the  presence  of  depression  at  the 
particular  moment.  In  general  dots  placed  below  the  line 
show  the  presence  of  unhealthy  emotions  as  fear,  hate,  anger, 
jealousy,  at  the  particular  moment.  A  dot  placed  above  the 
line  ab  indicates  in  this  case,  the  presence  of  a  feeling  of 
happiness.  In  general  dots  placed  above  the  line  indicate  the 
presence  of  healthy  emotions  as  courage,  love,  etc.  The  dis- 
tance of  the  dot  above  the  line  ab  indicates  the  strength  of 
the  particular  emotion  at  the  given  time.  Where  the  dots 
have  been  connected  together  by  a  line,  as  is  done  in  a 
temperature  chart,  the  emotion  chart  gives  one  a  detailed 
picture  of  the  particular  emotional  condition  from  hour  to 
hour.  From  it  one  can  get  information  in  regard  to  the 
effect  of  the  psychotherapeutic  advice  and  exercises  given. 
In  this  particular  case  the  consulter  was  at  first  in  a  con- 
tinuous state  of  depression.  After  beginning  to  use  certain 
of  the  exercises  discussed  below  to  bring  about  a  state  of 
happiness,  the  depressed  feelings  are  shown  by  the  chart  to 
have  decreased  in  strength  and  frequency,  and  at  various 
times  during  the  day  to  have  disappeared  completely.  This 
chart  can  be  made  use  of  in  a  variety  of  ways;  as  for  ex- 
ample, in  tracing  the  course  of  a  feeling  of  irritation  and 
nervousness,  in  showing  the  emotional  condition  from  hour 
to  hour  in  a  disturbance  having  a  manic  depressive  coloring, 
and  by  slightly  modifying  it  the  course  of  mixed  emotions  can 
be  shown.  One  value  of  a  chart  is  that  it  helps  to  arouse 
the  consulter's  ambition  to  keep  the  particular  emotion 
under  control  until  a  habit  is  established. 

Present  investigations  are  making  people  realize  more 
fully  that  the  mind  has  an  enormous  influence  on  the  body. 
The  experiments  of  Cannon  and  Crile  have  shown  us  con- 
clusively that  certain  emotions  are  physically  weakening  and 
others  life-giving;  that  one  of  the  most  important  things  in 


48  MENTAL  HYGIENE 

psychology  is  to  do  away  with  such  emotions  as  depression, 
fear,  hate,  anger,  jealousy,  etc., — the  weakening  emotions, 
and  to  substitute  for  them  joy,  courage,  love,  etc. — the 
strengthening  emotions.  In  general,  in  seeking  to  effect  the 
emotional  transformation  just  mentioned  an  application  of 
the  James-Lange  theory  of  the  emotions  has  been  made — 
"A  man  does  not  smile  because  he  is  happy  but  he  is  happy 
because  he  smiles."  The  consulter  was  directed  to  assume 
the  expression  of  face  and  body  that  corresponds  to  the 
particular  emotional  condition  which  I  wish  to  have  aroused, 
telling  him  that  the  mere  intimation  of  the  motion  produced 
it.  For  example,  if  a  feeling  of  courage  was  to  be  sub- 
stituted for  one  of  cowardice,  he  was  instructed  to  stand  up 
straight  and  sometimes  a  picture  was  put  before  him  to  look 
at  and  imitate.  A  photograph  of  the  equestrian  statue  of 
Joan  of  Arc  at  Rheims  I  have  found  very  effective  for  this 
purpose,  especially  when  in  large  size.  Again,  if  I  wish 
to  get  rid  of  a  habit  of  depression  and  sadness,  I  insist 
that  the  person  take  smiling  exercises  at  stated  intervals. 
Sometimes  he  has  not  laughed  for  so  long  a  time  that 
the  muscles  having  to  do  with  laughter  are  not  only  de- 
cidedly stiff  but  their  management  has  been  almost  for- 
gotten. Such  a  person  can  frequently  be  helped  in  this 
respect  by  looking  at  himself  in  a  mirror  struggling  to 
smile  or  at  a  large  smiling  face.  Persons  with  a  very 
strong  sense  of  humor  looking  at  the  picture  on  the  opposite 
page,  "Spring,  gentle  spring,"  which  I  reproduce  from  LIFE 
by  permission,  start  up  imitative  movements  of  other  parts 
of  the  body  as  well  as  those  of  the  face  and  for  this  reason 
it  is  particularly  good  for  this  purpose.  Reading  Mark 
Twain  and  other  humorous  writers  can  often  dispel  a  feel- 
ing of  depression  for  a  long  period. 


Spring,  Gentle   Spring 


METHOD  OF  RE-EDUCATION  49 

There  are  a  variety  of  things  that  a  consulter  can  be  in- 
structed to  do  to  dispel  an  unhealthy  emotion  when  it  arises. 
Using  a  hot  water  bottle  or  increasing  the  temperature  of 
the  room  will  frequently  help,  especially  if  the  fire  is  in  a 
fireplace  or  wood  stove ;  these  suggestions  are  not  hypotheti- 
cal, they  have  been  tried  and  they  work. 

2.  In  regard  to  strengthening  physical  and  psychical 
endurance.     Exercises    were     prescribed    through    which 
agreeable  associations,  or  those  having  an  indifferent  char- 
acter, were  built  up  with  the  irritating  phenomena.    Under 
the  use  of  these  the  unhealthy  effect  of  unpleasant  weather, 
noises,  sights,  smells,  tastes,  etc.,  have  vanished. 

3.  To     increase,     correct,     and     control     sensation. 
Where  a  visual  weakness  existed,  pictures  were  given  to  be 
examined.    After  this  was  done  what  had  been  seen  was  de- 
scribed and  the  omissions  and  additions  made,  as  regards  con- 
tent, were  pointed  out.    The  recording  of  the  result  in  each 
acted  as  a  stimulant.  Not  only  have  these  exercises  increased 
the  consultant's  powers  of  observation  but  the  reactionary  ef- 
fect on  his  whole  mental  life  has  been  beneficial.     For  the 
practical  value  of  such  an  exercise  in  a  normal  person,  we 
have   proof  in   the   extraordinary   observing   power   along 
visual  lines,  developed  by  Houdon  in  his  son  by  having  him 
slowly  pass  a  show  window  and  relate  afterwards  what  he 
had  seen  in  it ;  and  as  the  boy  became  more  expert  in  iden- 
tifying and  naming  the  objects  seen,  he  encouraged  him  to 
increase  his  speed  in  passing  such  a  window,  with  the  re- 
sult that  finally  he  could  run  past  a  show  window  and  name 
every  object  in  it.    Where  there  was  observation  and  memory 
weakness  along  other  sensory  lines  than  visual,  as  in  that  of 
hearing,  touch,  etc.,  appropriate  material  was  substituted  for 
the  visual. 


5O  MENTAL  HYGIENE 

4.  To  do  away  with  thought  confusion  and  the  attend- 
ant ineffective  action.      Here,  as  was  said  before,  a  weekly 
program  was  made  out  with  the  consulter  on  a  program 
blank,  and  he  has  at  the  given  hour  to  put  in  -f~  and  —  after 
each  item  to  show  when  he  has  followed  and  not  followed  it. 
The  program  given  is  brought  to  the  office  when  completed, 
for  discussion.    The  minds  of  many  consulters  have  cleared 
up  surprisingly  under  this  treatment. 

5 .  The  enlarging  and  controlling  of  conscious  and  sub- 
conscious mental  action  activity.     The  majority  of  mental 
difficulties  exist  because  certain  ideas  are  voluntarily  or  in- 
voluntarily dominating  consciousness.     This  is  because  of 
the  narrow  range  of  ideation  or  because  certain  ideas  have 
acquired  in  some  way  a  much  greater  energy  as  regards 
arising  and   controlling  consciousness.     The   effort  in   the 
exercises  given  here  is  through  applying  the  laws  of  mem- 
ory to  put  the  ideas  in  mind  which  will  compete  with,  and 
gradually  supplant  those  that  are  disturbing,  thus  giving  a 
healthy  direction  to  the  thinking.     For  this  purpose  appro- 
priate poems  have  been  learned  and  repeated  hourly  to  im- 
part   to   them    that    spontaneous    arising    character    which 
makes  them  real  competitors  of  the  ideas  one  wishes  to  sup- 
plant.    "The  Salutation  of  the  Dawn"  from  the  Sanscript, 
Kipling's  "If,"  "The  Twenty-third  Psalm,"  etc.,  have  been 
useful  for  this  purpose.     The  value  of  such  committing  to 
memory  was  strikingly  shown  in  the  improved  behavior  of 
two  children  who  when  brought  to  the  office  by  their  mother 
to   see   if  something  could,  not  be   clone   to   improve  their 
manners,  they  were  given  the  following  verse  by  Stevenson, 
("The  Whole  Duty  of  Children")  to  learn  and  recite  three 

times  daily: 


METHOD  OF  RE-EDUCATION  51 

A  child  should  always  say  what's  true, 
And  speak  when  he  is  spoken  to. 
And  behave  mannerly  at  table; 
At  least  as  far  as  he  is  able. 

A  short  quotation  containing  the  idea  one  wishes  to  fix  in 
mind  is  often  better  than  a  long  poem.  Several  of  the  fol- 
lowing have  been  used: 

Imitate,  you  will;  the  task  before  you  is  to  surround 
yourself  with  people,  etc.,  that  you  wish  to  imitate; 

The  aim  in  life  is  to  be  happy  yourself  on  a  high 
plane  and  to  make  others  so,  as  far  as  you  can ; 

If  a  man  does  not  know  to  what  port  he  is  start- 
ing no  wind  is  favorable  to  him; 

Use  your  senses,  for  they  furnish  you  with  the 
material  for  your  future  study  and  thought; 

What  you  shall  find  is  what  you  shall  take  with 
you; 

Growing  old  is  simply  living  on  one's  past; 

Learn  to  forget  the  useless; 

I  am  an  old  man  and  have  had  many  troubles 
but  most  of  them  never  happened; 

A  prophesy  helps  to  bring  about  its  own  fulfill- 
ment; 

To  understand  all  is  to  forgive  all; 

The  oftener  you  give  your  attention  to  a  thing  the 
oftener  the  thing  will  attract  your  attention; 

When  a  man  has  one  and  the  same  feeling  over 
and  over  again,  the  feeling  will  in  time  dominate 
the  man; 

What  we  think  and  feel  is  almost  as  important  as 
what  we  do; 

He  wins  who  laughs; 


52  MENTAL,  HYGIENE 

Thought   is   motor.      If   you   think   a    thing   long 
enough,  you  will  act  it  out; 

Think  before  you  act. 

Each  immoral  act  makes  reformation  more  diffi- 
cult. 

In  regard  to  influencing  the  sub-conscious  activity  which 
results  in  disturbing  dreams  that  the  trembling  state  on 
awakening  shows  to  be  injurious  to  the  nervous  system,  I 
have  made  scarcely  a  beginning,  but  when  I  think  of  the 
experiments  with  perfumes,  etc.,  through  which  dreams  have 
been  directed,  I  see,  as  I  have  said,  therapeutic  possibilities 
in  this  direction.  Not  alone  supplanting  is  to  be  done, 
usually  to  restore  one  to  mental  health,  but  a  systematic 
broadening  out  of  the  thought  content.  In  the  case  of 
adults  there  is  no  case  where  this  can  be  so  well  shown 
as  in  a  mental  hygiene  office.  Such  consulters  must  be 
advised  and  helped  in  doing  this  after  a  consideration  of 
their  personal  likes  and  capabilities. 

6.  To  break  up,  to  destroy,  and  banish  persistent  un- 
healthy images  and  ideas  means  the  formulating  of  exer- 
cises which  will  train  the  will  in  the  particular  case  to  act 
promptly  and  persistently  along  the  desired  line  when  oc- 
casion arises;  as  for  example  in  the  case  of  a  consulter 
who  had  an  apparition.     He  saw  a  ghost  at  intervals,  that 
is,  developing  a  definite  visual  image  which  on  occasions 
was  spontaneously  projected  into  space  and  had  to  be  done 
away  with  through  mentally  tearing  it  to  pieces  bit  by  bit. 

7.  The  materials  and  method  used  in  the  association  tests 
of  Woodworth  and  Wells,  in  the  completion  test  of  Eb- 
binghaus,  and  in  a  hundred  mental  tests,  are  useful   for 
increasing  accuracy  and  rapidity   in   thinking,— banishing 
mental  laziness. 


METHOD  OF  RE-EDUCATION  53 

8.  Increasing,  strengthening,  and  controlling  attention, 
memory,  and  imagination.  Where  there  is  a  weakness  in 
subjective  or  objective  attention  one  has  but  to  think  over 
laboratory  investigations  along  this  line  and  immediately 
a  corrective  means  is  at  hand.  Rapid  reading,  paragraph 
reproduction,  simple  and  complicated  calculations,  are  exer- 
cises that  strengthen  subjective  attention.  There  are  many 
useful  exercises  for  improving  attention.  Stimuli  can  be 
arranged  to  direct  the  consulter's  attention  away  from  one 
objective  field  to  another.  In  the  case  of  a  pain  in  the 
heart  region  that  has  become  more  or  less  a  habit,  a  con- 
suiter  has  been  trained  with  relieving  effect  to  direct  his 
attention  on  his  big  toe.  After  he  has  learned  to  make  this 
transfer  his  pain  has  lessened  considerably  and  sometimes 
entirely.  Each  of  us  has  favorite  or  preferred  fields  of  at- 
tention and  not  always  a  healthy  one.  That  this  can  be  al- 
tered by  arousing,  from  desire  of  good  health  or  from  neces- 
sity, an  interest  in  some  other  field  or  by  furnishing  the 
appropriate  stimuli,  goes  without  saying. 

Occasionally  weakness  of  attention  is  due  to  a  general 
relaxed  muscular  condition, — a  condition  only  favorable 
for  dreaming.  Muscular  tightening  up  is  fundamental  in 
bringing  full  attention  to  bear.  In  the  English  army  "brain 
drills,"  in  the  American  the  "setting  up  exercises"  show  that 
good  attention  power  is  partly  a  matter  of  muscular  adjust- 
ment and  muscular  strengthening.  The  value  of  training 
the  attention  from  a  therapeutic  standpoint  is  evident  from 
the  improved  physical  and  mental  condition  of  those  who 
have  been  in  Dr.  Vittoz's  sanatorium  where  attention  train- 
ing is  so  much  used  in  treating  the  patients.  Some  exer- 
cises he  uses  could  be  improved,  it  seems  to  me,  as  the  ban- 
ishing successively  of  several  objects  intentionally  recalled, 
and  the  differentiating  out  of  a  sound  and  hearing  it  alone ; 


54  MENTAL  HYGIENE 

this  could  be  done  through  making  use  of  some  of  the 
material  found  in  the  psychological  investigations  of  the  last 
ten  years.  In  the  mental  hygiene  clinic  one  clearly  becomes 
acquainted  with  attention  difficulties.  One  of  the  most  com- 
mon complaints  of  the  mother  who  brings  her  child  for 
treatment  is  that  he  is  inattentive.  Examination  very  often 
shows  that  his  inattentive  mental  state  grows  out  of  the 
kind  of  training  he  has  had  at  home.  There  may  be  some 
question  in  regards  to  the  desirability  of  military  training 
in  the  schools,  but  learning  to  stand  at  attention  when  told 
to  do  a  thing  and  being  sent  to  the  "guard  house"  in  case 
of  disobedience  should  be  introduced  into  home  life,  it 
seems  to  me. 

With  the  experimental  work  in  memory  everybody  is  so 
familiar  that  it  is  only  necessary  to  remind  the  reader  that 
many  consumers'  complaints  can  be  overcome  through  giv- 
ing the  exercises  which  will  be  immediately  suggested  if  one 
will  look  over  the  investigations  of  Ebbinghaus  and  those 
who  have  followed  him.  Above  all,  one  should  not  neglect 
the  studies  which  have  shown  the  value  of  one  repetition 
as  regards  retention,  and  the  ineffectiveness  of  "nagging" 
and  the  lesser  ability  to  recall  when  one  had  not  expected  to 
be  called  upon  to  reproduce  what  one  was  committing  to 
memory.  Exercises  in  imagination  are  needed  by  us  all, 
but  especially  by  those  troubled  with  mental  difficulties 
which  make  it  necessary  for  them  to  modify  their  old  ideals 
and  build  up  new  ones  in  order  to  get  well.  Imagination 
plays  such  an  important  role  in  the  life  of  each  individual 
in  the  way  of  suggesting  modes  of  action  that  we  should 
no  longer  neglect  cultivating  it  along  higher  lines.  One 
often  finds  in  investigating  cases  of  lying  and  stealing  that 
they  can  be  traced  to  an  imagination  which  should  have  been 
trained  long  before  to  work  in  legitimate  fields. 


METHOD  OF  RE-EDUCATION  55 

9.   In  connection  with  the  elimination  of  bad  habits 

and  the  establishment  of  desirable  ones.     I  made  constant 
use  of  James'  Principles: 

1.  Never  suffer  an  exception  to  occur  until  a  habit 
is  formed. 

2.  Seize    every    opportunity    for    strengthening   the 
habit. 

3.  Launch  habit  with  a  strong  and  decided  initiative. 

4.  Retain  faculty  of  effort  by  daily  exercise, 

and  those  of  Watson: 

1.  Within  certain  limits  the  less  the  frequency  of 
practice  the  more  efficient  is  each  practice  period. 

2.  The  less  the  number  of  habits   formed  simulta- 
neously, the  more  rapid  is  the  rise  of  any  given  habit. 

3.  WTithin  certain  limits,  the  younger  the  animal,  the 
more  rapidly  will  the  habit  be  formed. 

4.  The  higher  the  incentive  to  the  formation  of  a 
habit  and  the  more  uniformly  this  incentive  is  main- 
tained, the  more  rapidly  and  the  more  uniformly  will 
the  habit  he  formed.    Under  such  conditions  the  curve 
illustrating  the  growth  of  the  habit  will  rise  steadily. 

Whenever  the  incentive  decreases  in  intensity  (often- 
times with  the  actual  onset  of  boredom)  there  appear  pauses 
and  resting  places  in  the  curve  (places  of  no  improvement). 
It  becomes  the  work  of  the' clinical  psychologist  to  explain 
the  plateaus  in  the  work  curve,  for  the  consulter  becomes 
discouraged  when  he  sees  them  and  is  tempted  to  give 
up  his  practice.  I  have  found  Kraepelin's  curve  of  work 
useful  in  showing  the  consulter  the  meaning  of  "spurts," 
"warming  up,"  "over  fatigue,"  etc.,  in  the  work  connected 
with  forming  a  habit. 


56  MENTAL  HYGIENE; 

The  work  done  on  the  conditioned  reflex,  the  association 
reflex,  the  psychoreflex,  etc.,  suggest  methods  for  establish- 
ing desirable  habits.  Reflection  on  the  case  of  the  woman 
with  hay  fever  who  sneezed  on  seeing  artificial  roses  was 
suggestive  along  this  line.  Too  much  cannot  be  said  on  the 
development  of  useful  and  healthy  habits  of  a  child.  One 
is  constantly  surprised  by  physical  neglect  displayed  by 
parents  along  this  line.  The  inability  of  the  child  to  dress 
himself  and  assist  in  the  work  of  the  household  are  some 
of  the  many  things  that  migh  be  mentioned.  Parents  need 
to  look  over  life  and  decide  on  what  habits  the  successful 
person  must  acquire  and  with  this  ideal  in  mind  set  to  work 
to  train  their  children.  One  does  not  need  to  study  Mon- 
tessori  to  find  out  what  ought  to  be  taught  to  every  child. 
There  are  certain  things  that  every  human  being  has  to  do 
along  the  lines  of  household  economy  and  those  things 
should  be  taught  as  early  as  possible.  In  fact,  the  applica- 
tion of  the  good  common  sense  which  directed  our  grand- 
mothers in  their  parental  functions  would  make  us  all  good 
Montessori  teachers  without  much  special  preparation. 

10.  No  exercises  are  more  important  therapeutically  than 
those  for  increasing  rapidity  and  accuracy  of  movement  and 
eliminating  involuntary  abnormal  positions  and  movements. 
Everywhere  we  see  middle  aged  people  with  too  slow  a 
"tempo," — a  "tempo"  which  really  corresponds  to  a  de- 
creased quickness  in  thinking.  By  giving  physical  exercises 
for  increasing  the  quickness  of  movement,  through  con- 
ventional or  spontaneous  dancing,  especially  if  accompanied 
by  music,  it  is  surprising  how  much  the  consulter  improves 
in  what  he  can  accomplish  in  a  day  in  a  physical  way.  It  also 
restores  a  self-confidence,  and  does  away  with  an  indifferent 
attitude  which  is  unhealthy.  The  general  unmoral  effect 
of  a  slouchy  posture  ought  not  to  be  overlooked.  In  this 


METHOD  OF  RE-EDUCATION  57 

connection  the  mental  tests,  form-board  tests  for  example, 
furnish  abundant  material  for  exercises  and  one's  success 
in  carrying  out  the  instruction,  "speed  up,"  can  be  meas- 
ured by  using  a  stop  watch,  which  is  of  itself  a  stimulant. 
Even  speech  movements  need  to  be  increased  in  rapidity  in 
training  consulters.  I  have  found  rapid  reading  very  use- 
ful in  accomplishing  this.  The  real  reason  for  speeding  up 
movements  is  not,  of  course,  in  the  movement  itself,  but,  as 
was  said,  in  its  reactionary  effect  on  the  consulter's  think- 
ing. Through  it  his  mental  activity  gains  in  elasticity  and 
power.  In  cases  of  chorea,  etc.,  one  can  by  observation  easily 
invent  exercises  that  help  in  removing  abnormal  positions 
and  movements, — tics. 

ii.  Galbrith's  book  on  Fatigue  will  be  found  highly  use- 
ful in  bringing  out  muscular  relaxation  and  removing  fatigue. 
As  many  emotional  disturbances  are  doubtless  increased  by 
tenseness  and  fatigue,  it  is  extremely  important  to  remove 
them.  In  trying  to  do  this  I  do  not  encourage  long  rest 
periods.  Complete  physical  relaxation  during  ten  minutes' 
hourly  rests,  I  have  found  highly  beneficial  and  I  frequently 
prescribe  these.  Children  are  often  brought  to  a  psychologist 
for  advice  because  they  are  nervous  and  restless.  Very  often 
weariness  is  the  cause,  and  in  such  cases  I  advise  that  they 
lie  down  for  a  short  period  several  times  a  day.  The  "fights" 
and  "quarrels"  among  the  children  of  a  family  of  which 
so  many  mothers  complain,  can  be  controlled  by  putting  the 
children  in  separate  rooms  to  rest.  Their  affection,  solici- 
tude, and  devotion  to  each  other  after  even  a  short  period 
of  such  isolation  and  rest  is  almost  touching.  The  fact  that 
fatigue  grows  out  of  an  unnatural  bodily  position  when 
various  parts  of  the  body  are  not  in  equilibrium  and  results 
in  pain,  is  too  often  overlooked.  The  severe  pain  in  the 


58  MENTAL  HYGIENE 

back  of  the  neck  in  a  number  of  cases  has  immediately  dis- 
appeared on  ceasing  to  bend  over  in  working. 

12.  Increasing  through  practice,  ability  to  do  mental 
and  physical  work.     The  consulters  have  shown  a  decided 
increase   in    efficiency   through    previously   training   them- 
selves to  plan  and  execute  a  given  task  without  excitement 
or  previously  making  an  appropriate  plan  of  action. 

13.  The  restorative  value  and  the  injurious  effect  of  the 
imitation  of  others  are  factors  that  have  to  be  considered  in 
psychotherapy,  and  exercises  for  increasing  and  diminishing 
imitation,  suitable  to  the  particular  case,  have  to  be  devised. 
As  has  been  said,  not  alone  through  imitating  the  poses,  etc., 
of  real  people  but  even  of  those  in  pictures  one  can  fre- 
quently greatly  improve  one's  self  physically  and  mentally. 
In  connection  with  the  discussion  of  imitation  one  must  not 
neglect  to  speak  of  social  heredity.    Of  course  the  heredity 
of  every  child  should  be  carefully  looked  into  and  if  there 
are  any  mental  or  physical  disturbances  which  may  be  in- 
herited, the  child  should  be  made  immune  as  far  as  pos- 
sible through  appropriate  training.    Much,  however,  that  is 
called  "heredity"  is  nothing  more  than  imitation.     Cases 
for  example  of  pseudo-tuberculosis  and  other  diseases  are 
oftener  found  to  exist  in  families  where  there  is  a  reason 
to  believe  from  the  heredity  that  there  might  be  a  tendency 
in  this  direction.     The  unfortunate  part  of  such  beliefs  is 
that  the  fear  of  the  disease  and  the  constant  attention  upon 
the  particular  part  affected,  if  it  does  not  actually  produce 
the   disease,  at  least  probably  make  a  person  more  sus- 
ceptible to  it.     Social  heredity  is  strikingly  noticeable  in 
mos't  children.     One  sees  it  in  family  peculiarities  as  re- 
gards modes  of  expression  and  views  of  life. 

1 8.   Restoring  and  creating  normal  physical  functioning. 
T  frequently  teach  the  consulter  to  use  autosuggestion  on 


METHOD  OF  RE-EDUCATION  59 

account  of  its  great  value  as  a  pain  eliminator.  It  is  a  par- 
ticularly valuable  method  to  use  in  removing  depression. 
In  the  long  life  of  a  comparatively  delicately  constituted 
person  like  Kant,  we  see  the  health  significance  of  such  words 
as  "I  am  so  comfortable,"  as  a  preparation  for  going  to 
sleep.  If  one  doubts  the  significance  of  suggestion  as  a  pain 
instigator  and  destroyer,  let  him  say  over  and  over  again 
for  five  minutes  "My  head  aches"  and  observe  whether  he 
feels  as  comfortable  at  the  end  of  the  time. 

19.  It  may  seem  absurd  but  some  persons  have  to  be 
trained  step  by  step  to  participate  in  the  life  of  those  about 
them. 

20.  In  regard  to  building  up  a  sane  and  healthy  philos- 
ophy of  life.     In  many  cases  it  is  absolutely  necessary  not 
alone   to   get   at   a   consulter's   philosophy  of   life,   but   to 
modify  it.     One  finds  in  general  that  persons  with  mental 
and  nervous  troubles  have  none  or  that  it  is  inadequate  as  a 
guide  in  coping  with  a  difficult  situation.    Frequently  it  is  the 
idea  that  one  is  to  decide  as  to  what  he  will  do,  because  he 
likes  to  do  it,  and  their  liking  is  a  poor  guide  because  it  does 
not  rest  upon  a  high  emotional  or  intellectual  basis.     One 
has  two  things  in  dealing  with  many  consulters:  first,  to 
make  them  see,  which  is  always  difficult,  the  defect  in  their 
motivation  principle,  and  second,  to  urge  them  to  make  a 
substitution  for  it.     Frequently  they  have  not  only  not  the 
intelligence  but  they  lack  the  initiative  required  to  form  a 
new  one.     Often  the  psychologist  must  frame  a  philosophy 
very  simple  in  form  and  content  and  not  having  a  religious 
basis.    One  may  offer  some  one  else's  life  principle  that  ap- 
pears workable  as  that  of  Markham's  "The  Day  and  the 
Work:" 

To  each  man  is  given  a  day  and  his  work  for  the  day ; 
And  once,  and  no  more,  he  is  given  to  travel  this  way. 


60  MENTAL  HYGIENE 

And  woe  if  he  flies  from  the  task,  whatever  the  odds ; 
For  the  task  is  appointed  to  him  on  the  scroll  of  the  gods. 
Occasionally  I  give  my  own  principle  of  living  which, 
from  a  pragmatic  standpoint,  has  a  sound  basis  for  myself  in 
that  it  works  when  a  less  crude  and  bold  statement  fails  to 
help  me :  'I  am  here,  I  may  die  tomorrow,  I  may  live  twenty 
years  or  even  longer.  If  there  is  anything  after  death, 
everything  that  I  have  learned  through  suffering  as  well  as 
joy  will  be  a  valuable  asset.  If  there  is  nothing  hereafter  I 
shall  not  know  it."  The  establishment  of  a  philosophy  of 
life  is  not  of  course  needed  by  the  majority  of  consulters. 
It  is  most  needed  where  a  person  has  reached  the  point 
where  he  knows  he  is  failing  and  asks  himself  what  is  the 
use  of  the  struggle, — by  one  who  is  kept  from  ending  his  life 
perhaps  only  on  account  of  the  pain  and  awkwardness  of 
doing  so.  The  problems  of  people  in  general  as  com- 
pared with  the  persons  just  mentioned  are  rather  on  the 
surface,  and  aid  can  usually  be  given  by  direct  psychothera- 
peutic  advice  accompanied  by  the  giving  of  exercises,  things 
to  do,  which  will  act  in  the  way  of  mental  control  and  in  the 
establishment  of  healthful  and  habitual  modes  of  action. 
One  must  never  neglect  to  give  the  patients  something  to  do. 
It  makes  them  willing  to  leave  the  mental  hygiene  office 
without  the  more  tangible  physician's  prescription.  This  cor- 
responds to  a  prescription  and  to  the  taking  of  medicine 
which  patients  usually  feel  will  cure  them.  It  is  unnecessary 
to  amplify  this  matter  of  therapeutic  exercises  farther,  for 
enough  has  been  already  said,  doubtless,  to  give  an  idea  of 
how  the  consulter  is  made  a  participator  in  his  cure.  Just 
which  one  or  more  of  the  exercises  here  enumerated  should 
be  prescribed  in  a  given  case  depends,  of  course,  not  alone 
upon  the  consumer's  diffculties,  but  upon  his  personal  pecu- 
liarities. 


CHAPTER    SIX. 

A  DISCUSSION  OF  SOME  TYPICAL  CASES 

In  treating  most  of  the  persons  who  came  to  the  mental 
hygiene  clinic  several  different  therapeutic  methods  were 
employed.  This  has  made  it  seem  best  to  attempt  but  rarely 
to  give  illustrative  cases  under  the  different  methods  but  to 
devote  a  special  chapter  to  taking  up  in  an  illustrative  way 
several  cases,  stating  what  brought  the  persons  to  the  clinic, 
the  kind  of  treatment  given,  and  the  results  obtained. 

Case  I.  The  man  is  a  well-known  business  man.  He  reports  that 
he  trembles  so  violently  at  times  that  he  is  in  danger  of  falling  on 
the  street  and  that  this  is  accompanied  by  great  mental  distress. 
He  said  that  he  had  frequently  in  this  connection,  as  well  as  at  other 
times,  an  unpleasant  consciousness  of  his  finger  tips.  The  medical 
examination  which  I  insisted  on  his  taking  was  negative.  Phycho- 
analysis  brought  out  the  fact  that  he  was  much  troubled  by  an  act 
which  he  once  committed.  The  analytical  study  showed  that  it 
was  evidently  not  the  disgracefulness  of  the  act  itself  that  he  was 
so  much  worried  about  as  the  thought  that  if  it  were  known,  people 
would  ridicule  and  perhaps  avoid  him.  It  was  pointed  out  to  him 
at  once  that  there  was  no  possibility  of  the  acts'  becoming  known 
except  as  he  told  it.  Exercises  given  for  the  establishment  of  asso- 
ciative connections  that  would  give  rise  to  agreeable  emotions  when 
the  ideas  referred  to  arose,  were  helpful.  Through  looking  at  a 
smiling  face  or  resolutely  training  himself  to  smile  when  he  thought 
of  this  disagreeable  act,  there  was  gradually  connected  with  it  an 
agreeable  feeling,  and  the  trembling  and  other  physical  activities 
accompanying  fear  were  replaced  by  the  physical  activities  ac- 
companying amusement.  He  was  encouraged  successfully  to  stand 
up  and  exhale  while  thinking  of  the  act  just  mentioned,  to  face  the 
music  as  it  were.  To  get  the  help  of  unconscious  inner  imitation  in 
doing  this  he  was  advised  to  look  at  the  photograph  of  Joan  of  Arc 
previously  mentioned,  or  at  some  similar  picture.  As  it  was  found 
that  the  fear  periods  occurred  more  frequently  when  he  was  weary, 
short  rest  periods  at  frequent  intervals  were  advised.  To  remove  the 
unpleasant  consciousness  of  the  finger  tips  he  was  successfully 
trained  with  beneficial  result  to  use  it  as  a  signal  to  direct  his  atten- 
tion to  his  big  toe.  There  was  in  this  case  another  difficulty  which 
seems  to  be  entirely  independent  of  the  painful  experience  just  men- 
tioned. A  film  came  over  his  eyes  after  he  had  read  a  short  time 
and  he  felt  as  if  he  were  falling  asleep.  Here,  too,  mental  analysis 

Si 


62  MENTAL  HYGIENE 

reveals  the  difficulty.  By  nature  this  man  has  the  objective  habit. 
He  greatly  prefers  to  deal  with  the  external  world.  The  reading 
of  books  of  a  solid  character  he  finds  tiresome.  Unconsciously  this 
physical  difficulty  has  arisen  to  protect  him  in  doing  what  he  likes 
to  do. 

Case  2.  When  this  woman's  physician  went  to  the  war  another 
physician  referred  her  to  me.  She  had  been  in  bed  and  had  had  a 
trained  nurse  for  many  months.  Her  attacks  had  an  hysterical 
coloring-  and  her  physician  had  used  suggestion  to  quiet,  her  with 
<?ood  effect,  but  he  had  not  been  able  to  get  her  out  of  bed.  On 
examining  the  case  it  seemed  to  me  that  what  this  woman  ac- 
tually needed  was  re-education, — psychic  and  physical  hardening. 
She  was  advised  to  banish  her  food  antipathies,  to  be  less  sensi 
tive  to  slight  changes  of  temperature,  to  give  up  grumbling  at  the 
weather,  to  stop  considering  whether  she  was  in  pain,  particularly  to 
train  her  emotions,  as  hate  and  jealousy  evidently  played  a  very 
important  role  in  her  life.  Her  dreams  revealed  certain  of  her  de- 
bilitating ideas.  A  favorite  one  was  to  see  herself  combing  her 
hair  which  fell  out  as  she  combed  it.  Questioning  revealed  the 
fact  that  she  suffered  much  from  the  fear  of  losing  her  hair  which 
was  one  of  her  main  assets  as  regards  beauty.  Another  dream  was 
of  a  railroad  accident.  A  train  was  seen  falling  over  an  embank- 
ment. In  unraveling  this  dream  it  was  discovered  that  she  had  a  great 
horror  of  supporting  herself  and  as  she  and  her  husband  had  no 
money  laid  aside  she  worried  a  great  deal  lest  her  husband,  who  was 
a  traveling  man,  might  be  killed.  Through  psychotherapeutic  ad- 
vice and  the  employment  of  psychological  exercises  and  the  emotion 
chart,  she  has  recovered  sufficiently,  not  alone  to  manage  her  own 
household  successfully,  even  doing  much  of  the  housework  herself, 
but  to  take  part  in  the  social  life  of  the  community  in  which 
she  lives. 

Case  3.  A  woman  56  years  of  age  whose  movements  and  think- 
ing had  become  extremely  slow.  To  do  away  with  a  certain  stiff- 
ness and  slowness  of  movement,  a  Victrola  exercise  was  given, 
that  is,  she  was  instructed  to  set  the  Victrola  playing  some  spirited 
piece  of  music  and  after  having  removed  any  of  her  clothing  that 
would  impede  her  movements  to  respond  to  any  tendency  to 
movement.  To  increase  her  mental  activity  she  was  given  several 
of  the  attention  exercises  previously  mentioned,  especially  those 
haying  to  do  with  rapidity.  The  lightness  of  movement  and  the 
quickness  of  her  mental  response  which  is  today  observed  in  her, 
as  compared  with  her  former  heaviness  and  retardation  as  regards 
mental  and  physical  activity,  are  added  illustrations  of  the  effective- 
ness of  psychological  exercises. 

Case  4.  A  little  9  year  old  girl  brought  to  the  mental  hygiene 
clinic  by  a  school  nurse  because  she  was  lying,  doing  extremely  poor 
work  in  arithmetic,  and  at  home  crying  before  a  mirror  without 
any  apparent  cause.  For  example,  she  would  tell  a  well  connected 


DISCUSSION  OF  TYPICAL  CASES  63 

story  of  why  a  certain  child  she  did  not  know,  was  absent  from 
school.  The  Stanford  Revision  of  the  Binet-Simon  tests  showed 
that  this  child  was  of  superior  intelligence;  the  Healy  Aussage  and 
other  similar  picture-tests,  that  she  had  an  extremeyl  vivid  imagi- 
nation and  examination  snowed  that  her  first  training  in  arithmetic 
had  been  very  poor.  The  fact  that  she  belonged  to  a  family  of 
actors  and  that  they  had  cultivated  in  her  a  desire  to  make  an  im- 
pression threw  light  on  the  pleasure  she  took  in  sitting  before  a 
mirror  for  hours  crying.  A  few  private  lessons  in  arithmetic,  exer- 
cises to  train  her  in  exact  observation  and  narration  of  what  she 
saw,  and  a  talk  with  her  family  made  her  like  other  normal  chil- 
dren of  her  mentality. 

Case  5.  A  young  woman  who  suffered  from  fears  of  her  body, 
and  of^  crossing  the  Oakland  ferry.  She  had  been  taken  to  several 
specialists  in  Europe  with  no  good  effect.  One  of  them  told  her 
to  return  to  California  and  get  married,  which  she  did,  with  no 
beneficial  effect.  Whenever  she  crossed  the  Oakland  ferry  she  had 
an  image  of  herself  jumping  off  the  boat,  and  inner  speech  in- 
cluding words  stating  that  she  was  about  to  jump  into  the  bay.  In- 
structions were  given  her  as  regards  the  breaking  up  of  these 
images  which  were  so  distressing  to  her,  and  of  transferring  the 
inner  speech  on  such  occasions  to  more  healthy  subjects.  Work 
therapy  was  also  advised,  and  she  entered  the  university.  At  first 
she  was  encouraged  simply  to  listen  to  the  lectures,  but  later  to  pass 
an  examination  on  what  she  had  heard  in  the  lectures.  She  did  ex- 
cellent work  and  today  is  in  good  mental  and  physical  condition. 

Case  6.  This  is  a  boy  of  15  sent  from  one  of  the  schools,  who 
wished  to  go  to  work.  The  following  is  taken  from  the  report  to 
the  teacher  who  sent  him  for  examination :  C.  is  normal  and  not 
feeble-minded  as  you  inferred  from  the  character  of  his  school 
work.  In  view  of  his  complete  lack  of  interest  in  his  school,  the 
poor  home  conditions,  and  the  mature  character  of  the  place  in  which 
he  is  now  working,  I  advise  that  he  be  granted  a  work  permit. 

The  position  he  now  has  at  the  Riddle  Sheet  Metal  Works  is  not  a 
"blind  alley  job,"  leading  nowhere,  but  is  the  first  step  in  a  kind 
of  work  which  will  eventually  lead  to  a  good  position  in  the  indus- 
trial world.  Mr.  Riddle  says :  ''This  boy  is  in  a  position  to  learn  the 
sheet  metal  trade  and  this  will  be  of  advantage  to  himself  as  well  as 
to  his  parents." 

The  following  is  a  copy  of  the  report  of  the  social  worker,  who 
went  to  the  Riddle  Sheet  Metal  Works  to  look  into  the  character 
of  C.'s  work  there:  "Called  at  the  Riddle  Sheet  Metal  Works, 
where  C.  is  employed.  Spoke  to  Mr.  Riddle,  who  says  that  C. 
has  been  working  for  him  all  vacation  and  has  given  satisfaction. 
He  says  that  the  boy  is  interested  in  his  work  and  will  gradually 
learn  the  business  and  become  a  skilled  mechanic.  He  reports  that 


64  MENTAI,  HYGIENE 

he  is  prompt,  willing,  and  intelligent,  that  the  union  requires  him  to 
attend  night  classes  twice  a  week,  and  wrote  a  card  to  that  effect. 
C.'s  uncle,  who  is  a  very  capable  worker  there,  spoke  of  C.  as  "a 
good  boy." 

Case  7,  8  and  9.  I  quote  the  following  from  reports :  That  part 
of  R.'s  examination  which  has  to  do  with  the  use  of  the  Binet-Simon 
tests  shows  that  his  mental  age  is  seven  years  and  eight  months ; 
that  is,  he  is  approximately  a  half  year  in  advance  in  intelligence 
of  the  average  child  of  his  age. 

In  tests  requiring  logical  judgment,  in  short,  good  common  sense, 
he  is  unusually  strong.  He  is,  however,  deficient  in  certain  mat- 
ters that  most  children  know.  For  example,  he  is  unable  to  identify 
money.  This  lack  is  not  merely  a  matter  of  identification  of  the 
coins — he  has  not  the  knowledge  of  a  child  of  his  age  of  the  in- 
trinsic value  of  money.  It  seems  to  me  this  should  be  corrected  and 
farther  that  he  should  be  given  a  small  weekly  allowance  and  be 
taught  habits  of  saving  a  portion  of  it  through  the  use  of  a  savings 
bank  and  the  buying  of  thrift  stamps.  In  connection  with  the 
thrift  stamps  it  is  possible  to  give  him  a  great  deal  of  information 
about  our  present  war  which  will  be  valuable  to  him  when  he 
grows  up.  I  am  sure  from  my  own  experience  as  a  child,  that  he  is 
not  too  young  to  be  given  information  along  this  line. 

He  does  not  use  his  hands  well.  He  was  unable,  for  example, 
to  tie  a  bowknot.  The  effort  of  learning  to  do  simple  acts  of 
this  kind  gives  an  independence  and  persistence  in  keeping  at  a 
thing  which  is  essential  in  life.  Want  of  persistence  in  trying  to  do 
a  thing  in  which  he  is  not  interested,  is  a  marked  weakness  in  R.'s 
makeup.  He  gives  up  too  easily.  There  should  be  special  training 
along  this  line  also. 

R.  is  not  up  to  a  child  of  his  intelligence  in  the  understanding  of 
words.  You  may  think  it  well  in  reading  to  him  to  find  out 
whether  he  is  understanding  the  individual  words.  His  enjoyment 
of  something  read  may  not  alone  be  in  the  general  understanding 
of  what  is  read  but  in  the  rhythm  of  the  reader's  voice. 

The  boy's  eyes  seem  to  be  quite  normal,  but  his  hearing  is  not 
very  acute.  I  think  this  partly  due  to  his  listening  to  the  general 
content  of  the  thought,  which  is  a  thing  that  often  marks  a  some- 
what impatient  nature.  Such  persons  listen  not  to  the  sound  of  the 
word,  but  to  its  meaning.  That  is  to  say,  R.  listens  with  a  view  to 
getting  the  meaning  of  the  sentence  and  not  to  the  words  themselves. 
If  he  were  trained  to  hear  the  words  also  it  would  doubtless  in- 
crease his  appreciation  of  musical  sounds.  While  on  the  matter  of 
sound  appreciation,  I  might  add  that  as  I  discussed  his  music  les- 
sons with  him  I  was  led  to  question  whether  such  Victrola  records 
are  being  used  as  will  train  him  in  the  high  musical  appreciation 
which  you  desire. 


DISCUSSION  OF  TYPICAL  CASES  65 

R.  has  a  good  imagination  and  is  cautious  in  expressing  his 
opinion  on  matters  with  which  he  is  not  acquainted.  The  answers 
to  the  ethical  questions  showed  that  he  also  had  correct  ideas  along 
moral  lines,  and  the  Healy  Aussage  test,  that  he  is  not  very  sug- 
gestible. 

All  the  children  lisp.  The  sound  "th"  at  the  beginning  of  a 
word  is  frequently  changed  to  "d."  "Th"  is  also  not  brought  out 
clearly  at  the  end  of  a  word ;  the  same  is  true  of  "sh"  at  the  be- 
ginning and  end  of  a  word.  I  am  enclosing  some  words  which  I 
suggest  you  have  all  the  children  pronounce  daily  until  this  habit 
is  corrected,  as  there  seems  to  be  no  organic  basis  in  any  of  them 
for  this  difficulty.  The  meaning  of  some  of  the  words  I  send  they 
will  not  understand.  I  regard  this  as  not  a  bad  thing  in  that  they 
will  be  forced  to  listen  to  sounds. 

I  suggest  that  you  have  your  nurse  give  R.  some  exercises  which 
will  help  him  to  control  his  unnecessary  movements,  growing  doubt- 
less out  of  his  nervousness. 

I  suspect  from  his  answers  to  certain  tests,  that  R.  plays  largely 
with  little  girls ;  would  it  not  be  desirable  for  him  to  have  more  boy 
companions?  This  might  help  to  do  away  with  the  "bullying"  of  his 
sister,  of  which  you  spoke,  though  I  think  it  could  be  better  re- 
moved through  appealing  to  the  chivalric  side  of  his  nature. 

This  boy  is  an  unusually  fine  child.  In  general,  what  ought  to  be 
given  is  psychic  hardening  and  a  greater  knowledge  of  the  practical 
world.  It  would  be  well,  it  seems  to  me,  to  put  him  in  a  public 
school  after  this  term.  Through  having  ito  mingle  with  $all 
classes  of  children  a  child  like  R.  will  acquire  a  certain  mental  and 
physical  sturdiness  which  will  be  of  great  service  to  him  later  in  life. 

L.'s  examination  shows  that  she  is  approximately  normal,  al- 
though she  was  unusually  slow  in  her  answers  to  the  test  questions. 
In  her  case,  as  in  R.'s,  there  is  a  tendency  to  react  well  along 
common  sense  lines  but  it  is  by  no  means  as  well  developed  in  her  as 
in  him.  She,  too,  lacks  the  information  in  regard  to  money,  etc., 
which  a  child  of  her  age  ought  to  have. 

L.  is  extremely  nervous  and  should  be  given  frequent  short  periods 
of  relaxation  and  rest.  She  makes  the  peculiar  vocal  sounds  which 
are  so  noticeable  in  the  case  of  little  F.  She  is  not  slow  in  re- 
acting to  her  emotions.  If  she  understands  a  thing  and  feels  like 
doing  it,  she  acts  almost  too  quickly.  Where  feeling  is  the  motive 
power  she  ought  to  be  trained  to  think  before  she  acts.  The  child's 
emotional  life  needs  special  development.  Certain  emotions  as 
jealousy,  I  suspect,  play  too  prominent  a  part  and  ought  to  be  sup- 
planted by  those  that  will  develop  a  finer  character. 

L.'s  will  also  needs  training.  From  my  experience  with  her,  I 
judge  that  she  is  too  much  inclined  to  insist  upon  having  her  own 
way,  and  I  should  not  be  surprised  to  hear  that  she  did  not  get  on 
well  with  other  children  except  as  they  give  up  to  her  desire.  If 


66  MENTAI,  HYGIENE 

this  is  so,  she  ought  to  be  forced  to  consider  other  people's  wishes. 
f  think  if  L.  were  given  some  animal  she  likes  to  care  for,  when  you 
go  down  to  the  country  this  summer,  it  would  help  to  develop  in 
her  consideration  for  other  beings.  She  is  too  self  centered. 

F.  is  mentally  retarded,  but  I  feel  confident  that  if  proper  training 
is  given  to  her  while  her  mind  is  in  a  plastic  condition,  this  retarda- 
tion can  be  lessened  and  perhaps  entirely  overcome.  She  should  be 
trained  along  the  line  of  initiative  and  her  very  marked  tendency  to 
imitation  should  be  discouraged.  I  think  it  would  be  an  excellent 
thing  if  she  could  be  taken  away  from  the  other  children,  who  have 
very  strong  wills,  for  the  next  few  months,  perhaps  to  one  of  the 
cottages  on  your  country  place,  and  trained  with  two  or  three 
children  of  her  own  age  by  Miss  S.  Such  training  would  prepare 
her  to  enter  the  kindergarten  later.  If  you  wish,  I  shall  be  glad 
to  give  directions  to  Miss  S. 

F.  ought  to  have  very  much  more  mental  rest  than  at  present. 
The  imitation  and  the  want  of  initiative  of  which  I  speak  is  not 
alone  due  to  the  fact  that  she  is  with  the  two  older  children  who 
have  very  strong  wills,  but  also  to  being  in  an  atmosphere  which 
makes  too  great  demands  upon  her  mental  life." 

Case  10.  The  following  extracts  from  a  report  made  to 
the  Red  Cross  which  sent  the  case  to  me,  give  an  idea  of  the 
work  that  is  being  done  with  returned  soldiers  along  place- 
ment lines.  Mr.  M.  joined  the  Anzacs  in  1916.  His  first 
fighting  was  at  Gallipoli  where  he  was  under  fire  from  the 
Turks  for  28  days.  He  was  then  sent  to  the  hospital  for 
shell  shock  and  later  received  an  honorable  discharge.  For 
months  he  traveled,  working  in  Australia,  New  Zealand,  and 
Hawaii  when  able,  ultimately  reaching  San  Francisco,  where 
he  was  referred  by  the  Red  Cross  to  the  Mental  Hygiene 
Clinic.  At  this  time  he  was  in  a  highly  nervous  condition, 
having  convulsive  movements  of  the  eyes  and  face,  and 
stuttering  excessively. 

Vocational  mental  tests  made  by  Mr.  M.  shows :  Efficiency,  i.  e., 
intelligence,  good;  education,  fair;  industrial  training,  good.  My 
opinion  on  examining  him  was  that  the  peculiar  movement  of  his 
eyes  were  partly  the  effect  of  shell  shock  and  partly  due  to  his  being 
far-sighted,  and  that  his  stuttering  went  back  to  early  childhood, 
but  has  doubtless  been  increased  by  the  shell  shock.  In  the  treat- 
ment of  this  case  it  will  be  necessary  to  give  psychotherapeutic  ad- 
vice and  exercises  to  enable  him  to  overcome  the  fears,  etc.,  which 


DISCUSSION  O?  TYPICAL  CASES  67 

lie  at  the  base  of  his  stuttering  and  of  the  peculiar  movements  con- 
nected with  the  eyes.  As  his  former  occupation  had  been  that  of  a 
lathe  worker  it  was  thought  best  to  place  him  at  this  kind  of  work, 
in  a  small  shop  where  there  is  less  noise,  as  the  noise  of  a  great 
shop  brings  all  his  experiences  in  the  battlefield  and  utterly  incapaci- 
tates him  for  work;  also  that  his  sleeping  would  be  improved  in  a 
quieter  room  than  the  one  he  occupies  at  present.  He  was  re- 
ferred to  the  Eye  Clinic  and  the  following  is  the  report  of  the  social 
worker  who  accompanied  him : 

Mr.  M.  reported  to  the  Eye  Clinic  where  it  was  found  that  he  had 
long  suffered  from  eye  strain  caused  by  extreme  far-sightedness. 
There  was  also  a  slight  infection  in  the  right  eye  of  a  temporary 
nature.  For  this  latter,  drops  were  prescribed  for  daily  use  and 
he  was  ordered  to  report  a  week  later.  One  week  from  this  time  it 
was  found  that  the  infection  of  the  right  eye  was  cured.  Drops 
were  given  to  dilate  the  pupils  and  this  treatment  was  ordered  con- 
tinued for  five  days.  He  was  to  report  one  week  from  date  to  be 
measured  for  glasses.  During  this  time  his  eye  condition  incapaci- 
tated him  for  work.  A  week  later  it  was  found  that  the  pupils  had 
not  contracted  sufficiently  to  measure  him  for  glasses  and  counter- 
acting drops  were  given  to  contract  the  pupils.  He  was  to  return 
in  one  week  for  his  glasses.  His  eye  condition  during  this  time  did 
not  prevent  his  going  to  work." 

The  social  worker  on  this  case  secured  for  Mr.  M.  employment 
in  a  garage,  where  he  is  to  work  at  truck  repairing  in  a  separate 
room  given  over  to  this  work.  Mr.  M.  and  the  owner  of  the  garage, 
to  whom  all  the  details  of  the  case  had  been  previously  explained, 
have  met  and  talked  over  the  matter  of  present  employment  and 
possible  advancement.  Ten  days  from  his  first  visit  Mr.  M.  came 
to  my  office.  His  general  condition  seemed  greatly  improved,  he 
sleeps  better  at  night,  having  changed  to  a  quieter  room,  and  he  is 
to  continue  with  the  treatment  previously  prescribed. 

It  is  in  general  my  custom  to  require  a  physical  examination,  but 
as  Mr.  M.  said  that  he  had  been  physically  examined  within  the  last 
four  months,  and  as  he  had  strenuously  objected  to  a  re-examina- 
tion, I  waived  it  in  this  case. 

Though  this  placement  seems  satisfactory  as  regards  his  present 
condition  I  shall  continue  with  the  psychotherapeutic  treatment 
until  he  is  completely  rehabilitated. 


CHAPTER    SEVEN. 

THE  PART  OF  THE  SOCIAL  WORKER  IN  MENTAL 
HYGIENE  DIAGNOSIS  AND  TREATMENT 

It  ought  to  be  emphasized  in  a  discussion  of  any  psycho- 
therapeutic  treatment  that  proper  social  service  work  is 
almost  indispensible.  Persons  who  do  this  work  satisfac- 
torily must,  of  course,  have  some  special  training  for  it,  and 
this  I  have  tried  to  give  to  those  working  with  me.  All  were 
required  to  read  MENTAL  HYGIENE,  THE  SURVEY,  the  Gov- 
ernment publications  on  Rehabilitation,  etc.,  and  their  con- 
tent was  discussed.  Each  of  the  workers  was  given  cer- 
tain visits  to  make.  Of  these  visits  they  prepared  type- 
written reports  which  were  discussed  and  criticised  at  the 
mental  hygiene  social  workers'  meeting.  They  were  also 
given  reading  to  do  along  the  lines  of  the  disturbances  of  the 
consulters  they  were  visiting,  of  which  they  made  a  sum- 
mary, and  reported  on  points  that  they  thought  applicable. 
As,  for  example,  when  the  person  they  had  in  charge  was 
alcoholic,  they  read  in  medical  books  on  the  subject,  tak- 
ing careful  notes  as  to  the  cause  and  treatment  of  such 
cases.  Armed  with  this  knowledge  and  the  previous  general 
discussion  of  such  cases  they  set  out  to  investigate  the  par- 
ticular case,  noting  the  respects  in  which  it  resembled  and 
did  not  resemble  the  cases  of  which  they  had  read.  Later 
this  case  was  again  taken  up  with  them.  The  workers  were 
taught  to  take  a  consulter's  history  and  to  make  a  Binet- 
Simon  test,  where  it  seemed  necessary  and  the  case  was  not 
too  complicated.  Where  a  case  required  placement  in  cus- 
todial care  of  an  adult  or  child  arose,  they  set  to  work  to 
inform  themselves  regarding  the  available  institutions  of  the 
city  and  state,  and  after  this  had  been  done  the  placement 
was  taken  up  in  a  meeting  and  decided  upon. 

68 


SOCIAL  WORKER   IN    MENTAL   HYGIENE  69 

The  success  of  the  mental  hygiene  clinic  depends  largely 
on  the  social  worker's  cooperation  in  a  variety  of  ways. 
This  is  particularly  true  of  her  management  of  the  recep- 
tion room  of  the  clinic,  not  only  in  her  kind  and  polite  re- 
ception of  the  consulters  but  in  such  an  attitude  towards 
the  director  as  increases  their  confidence  in  the  psycho- 
therapeutic  treatment  offered,  and  leads  them  to  put  forth 
their  best  efforts  to  carry  out  the  advice  and  exercises 
given.  The  treatment  of  the  children  while  they  are  wait- 
ing their  turn  is  also  very  important.  The  kind  of  prepara- 
tory preparation  for  treatment  was  particularly  well  done 
in  the  case  of  a  little  boy  who  replied  "I  won't"  to  every- 
thing he  was  asked  to  do  even  when  he  afterwards  obeyed. 
He  was  shown  into  the  office  by  the  social  worker,  very 
formally  introduced,  and  then  told  to  be  seated.  I  said  to 
him,  after  she  had  left  the  room  and  closed  the  door,  that 
the  Mental  Hygiene  Clinic  of  the  San  Francisco  'Polyclinic 
had  heard  that  he  was  repeatedly  saying  "I  won't"  at  home 
and  was  making  his  mother  very  nervous  by  so  doing,  and 
asked  him  if  it  was  true.  Kicking  his  legs  against  a  chair 
and  looking  at  the  ceiling  he  replied,  after  a  pause,  "Yes." 
I  then  said  that  the  Mental  Hygiene  Clinic  of  the  San  Fran- 
cisco Polyclinic  had  decided  that  he  must  say  this  no  more 
and  asked  him  if  he  was  ready  to  obey.  He  answered 
"Yes,"  and  I  arose  and  bowed  him  out.  From  that  day  to 
this  the  words  "I  won't"  and  his  antagonistic  attitude  at 
home  have  entirely  disappeared. 

The  disorder  that  sometimes  arises  and  which  is  so  dis- 
tracting in  the  ante-room  of  a  clinic  must  be  avoided  by 
giving  the  child  something  to  do  that  will  amuse  him  and 
yet  keep  him  in  an  expectant  state  as  regards  his  turn. 
The  kind  of  toys  that  are  useful  in  this  work  and  for 
education  purposes,  in  general,  for  the  various  children  has 


70  MENTAL  HYGIENE 

been  taken  up  at  the  social  service  meetings  and  the  theories 
advanced  have  been  later  tested.  We  have  all  come  to  see 
that  toys  have  a  more  important  place  in  mental  hygiene 
work  than  we  had  supposed.  This  was  particularly  well  seen 
by  a  social  worker  who,  in  order  to  get  better  acquainted 
with  a  family,  invited  the  mother  and  her  two  children  to 
afternoon  tea.  After  the  little  boys,  who  lived  in  one  small 
room  at  home,  had  covered  the  windows  with  pictures,  set 
all  the  water  faucets  in  the  house  running,  and  had  done 
various  other  unconventional  things,  the  social  worker 
understood  better  the  significance  and  value  of  having 
proper  toys  on  hand  for  such  occasions. 

It  is  also  absolutely  necessary  to  have  good  social  work- 
ers, in  order  to  carry  on  the  outside  work  of  a  mental  hy- 
giene clinic  successfully.  As  has  been  said  so  often  lately, 
satisfactory  social  work  is  family  work.  Mental  trouble 
often  has  its  cause  in  the  family,  in  the  environment  of  the 
patient,  hence  social  service  work  is  needed.  Usually  the 
family  must  be  treated  in  order  to  cure  the  patient.  I  have 
occasionally  heard  ignorant  and  unthinking  persons  'sug- 
gest that  the  children  must  be  taken  care  of;  by  inference 
leaving  the  impression  that  the  parents  can  be  left  to  go 
their  own  wrong  way.  This  is  absolutely  impossible  if  one 
wishes  to  get  proper  ideas  into  a  child's  mind.  We  have 
abundant  proof  of  it  in  the  ineffective  work  done  in  schools, 
in  the  case  of  ignorant  and  unprincipled  families.  In  gen- 
eral the  parents  give  the  child  the  principles  which  really 
govern  his  thoughts  and  actions.  If  we  don't  agree  with 
them  we  must  begin  the  reformation  in  the  family  through 
the  social  worker  in  the  family.  Again,  in  dealing  with 
children  in  institutions,  although  the  ideas  they  are  gleaning 


SOCIAL  WORKER  IN  MENTAI,  HYGIENE  Jl 

from  those  around  them  are  more  in  harmony  with  our 
own,  we  see  that  the  institutional  training  is  not  preparing 
them  to  found  a  family  or  go  into  some  one's  else  family 
and  deal  efficiently  with  its  work.  One,  for  example,  who 
has  washed  and  wiped  dishes  and  done  other  household  work 
with  a  group,  has  not  acquired  the  initiative  that  enables 
him  to  work  advantageously  alone.  It  is  the  same  with 
other  matters.  Group  work  is  different  from  individual 
work.  The  child  must  remain  in  the  family,  and  where  the 
family  is  failing  in  giving  him  proper  training,  an  effort 
must  be  made  through  social  service  work  to  reform  the 
family. 

In  the  last  two  years  I  have  seen  much  accomplished  by 
the  social  workers  in  the  direction  of  family  training.  The 
following  is  typical.  A  child  was  sent  from  the  Children's 
Clinic  to  the  Mental  Hygiene  Clinic  because  he  lisped.  Ex- 
amination gave  no  proof  of  a  physical  cause.  It  was  clearly 
a  case  of  imitation  and  carelessness.  The  social  worker 
visited  the  family  to  arrange  for  some  one  to  help  in  the 
vocal  training.  She  found  a  house  which  the  family  entered 
by  climbing  through  a  window.  Some  "squabble"  with  the 
landlord  had  prevented  the  replacing  of  a  key  which  had 
been  lost.  The  social  worker  entered  the  house  by  the 
family  entrance;  that  is,  by  climbing  through  the  window. 
She  found  everything  in  disorder  and  dirty.  She  talked 
with  an  older  sister  and  showed  her  how  to  help  her  mother 
to  speak  more  correctly.  This  was  the  open  sesame  to  the 
family.  Gradually  the  neighborhood  quarrel  was  put  an  end 
to,  the  front  door  was  gotten  open,  and  the  children  stimu- 
lated to  clean  up  the  house.  The  house  was  in  the  suburbs 
and  the  truant  officer  had  not  noted  the  little  boy's  non-at- 
tendance at  school.  At  last  the  mother  was  aroused  to  the 


72  MENTAL  HYGIENE 

importance  of  not  only  sending  him  to  school  but  also  of 
taking  part  in  keeping  her  house  in  order.  Result, — a 
family  set  on  a  self-respecting  basis,  and  a  little  boy  who  no 
longer  lisps. 


CHAPTER  EIGHT. 

THE  EFFECT  OF  MENTAL  HYGIENE  TREATMENT 
ON  THE  CONSULTERS 

In  view  of  the  heightened  feeling  of  well-being  and  hap- 
piness on  the  part  of  many  of  the  consulters  and  their  in- 
creased effectiveness  in  their  daily  work,  I  should  say  that 
the  mental  hygiene  treatment  here  discussed  had  been  decid- 
edly beneficial.  That  those  outside  of  the  enthusiasm  that 
comes  from  being  directly  engaged  in  the  work  also  think 
well  of  it  is  shown  in  the  following  account  of  the  work  of 
the  mental  hygiene  clinic  which  was  published  in  the  last 
annual  report  of  the  San  Francisco  Polyclinic,  by  Miss  Elsie 
Krafft,  head  of  the  Social  Service  Department : 

The  first  Mental  Hygiene  Clinic  on  the  Pacific  Coast  was 
opened  at  the  San  Francisco  Polyclinic,  February,  1917, 
under  Dr.  Lillien  J.  Martin,  consulting  psychologist,  with  a 
view  to  restoring  mental  health  through  the  application  of 
recent  investigations  in  phychology.  The  results  have  jus- 
tified the  experiment.  To  have  even  a  slight  knowledge  of 
the  sufferers  who  come  for  help  is  to  realize  the  need  of  such 
a  clinic.  The  tragedy  of  warped  and  thwarted  lives  is  here ; 
lives  haunted  by  strange  fears  and  obsessions ;  weighted  with 
intolerable  burdens,  often  imaginary,  but  none  the  less 
heavy;  lives  unfulfilled  and  unreconciled.  To  these  the 
Mental  Hygiene  Clinic  brings  new  hope,  a  wider  outlook 
and  re-education  for  the  hitherto  distasteful  task  of  living. 

Re-education — that  is  the  key-note!  Definite,  systematic 
training  based  on  scientific  findings  in  the  great  research 
laboratories  of  Europe  and  America.  Let  its  scientific  basis 
be  clearly  understood  from  the  beginning.  Mental  hygiene 
is  not  a  mere  secular  confessional.  It  is  not  a  place  where 

73 


74  MENTAI,  HYGHCN* 

the  neurotic  and  the  neurasthenic  may  dramatize  themselves 
and  luxuriate  in  their  own  emotional  outpourings.  They 
will  only  too  readily  do  this  on  the  slightest  provocation  and 
need  no  further  encouragement.  The  confession,  tho  it  has 
a  place  in  diagnosis  and  its  value  in  therapeutics,  is  only  part 
of  a  cure.  Nor  is  mental  hygiene  mere  friendly  talk  where 
soothing-syrup  wisdom  is  dispensed  in  regular  doses.  Men- 
tal hygiene  has  nothing  in  common  with  those  rarified  "phil- 
osophies" which  lay  stress  on  things  that  are  not  so  and 
never  face  the  things  that  are.  Mental  hygiene  fronts  the 
realities  of  our  complex  human  nature,  with  its  fundamental 
instincts,  its  insistent  needs,  its  strivings  and  satisfactions, 
and  never  ventures  to  exorcise  a  mental  conflict  with  a 
"Don't  Worry"  book. 

In  the  long  file  of  those  who  come  for  help  (445  patients 
since  the  inception  of  the  clinic),  are  the  depressed  who  have 
lost  all  ambition ;  the  terror-stricken  in  the  shadow  of  mental 
breakdown ;  those  with  weakening  memories,  no  longer  able 
to  control  their  emotions  or  to  concentrate  their  thoughts; 
"shut-in"  personalities,  secluded  in  their  own  torturous 
thinking  and  imagining  themselves  slighted  or  shunned; 
neurasthenics  lacking  the  initiative  to  find  a  position ;  mis- 
fits in  uncongenial  vocations ;  the  prematurely  old  and  women 
in  the  menopause ;  the  psychopaths  and  the  insane ;  hysterical 
adolescents;  feeble-minded  and  incorrigible  children. 

METHOD    OF    DIAGNOSIS — GET    THE)    THOUGHT    FROM    UNDER 
THE  THRESHOLD 

First  comes  the  diagnosis  by  introspection.  The  patient 
is  asked  to  tell  the  story  of  his  life.  Sometimes  this  brings  a 
complete  confession :  often  the  vital  facts  are  withheld,  and  it 
is  necessary  to  search  the  dream-life  for  a  clue,  or  to  study 
word-associations  to  discover  where  the  patient  is  attentive 
to  something1  under  the  threshold.  Mistakes  and  for- 


EFFECT  OF  MENTAL  HYGIENE  TREATMENT  75 

gettings,  the  reaction-time  of  a  single  word — all  are  sig- 
nificant of  a  possible  repression  that  may  indicate  the  deep- 
seated  mental  conflict  at  the  base  of  a  psychosis.  These  con- 
stitute the  psycho-analytic  method  of  Freud,  the  great  revo- 
lutionist who  startled  the  medical  world  with  his  theory  of 
the  subconscious  in  relation  to  mental  disease.  It  is  the 
endeavor  of  the  psychologist  to  plumb  the  subconscious  mind, 
that  storehouse  of  experiences  hoarded  by  the  senses,  and 
find  the  hidden  thought  or  the  balked  instinct,  pushed  down 
below  consciousness,  repressed  yet  still  functioning  and 
dominating. 

METHOD  OF  TREATMENT — RE-EDUCATION 

The  "complex"  at  last  revealed  and  faced,  the  next  step  is 
in  the  direction  of  re-education  of  thought  and  will  to  the 
end  that  a  better  adjustment  to  environment  may  be  made. 
To  some  are  given  exercises  for  attention,,  to  others  exercises 
for  emotional  and  thought  control.  Some  are  required  to 
keep  an  emotion  chart,  recording  their  daily  fluctuations  of 
depression  and  excitement.  For  many  there  is  work  therapy. 
When  we  move  we  think  and  in  dementia  precox  the  throw- 
ing of  a  bean  may  be  intellectual  achivement. 

TYPICAL  CASES. 

Mr.  X.,  once  a  skilled  mechanic,  had  gradually  slumped  down 
till  he  could  no  longer  earn  a  living.  Complaining  of  headaches, 
deafness,  insomnia,  and  finally  confessing  to  a  fear  of  homicidal  im- 
pulses, he  drifted  from  clinic  to  clinic  for  eight  unhappy  years.  The 
history  begins  with  an  accident  in  the  machine  shop  where  he  worked. 
"Contusion  of  the  neck  and  hysterical  mania"  was  the  diagnosis  with 
which  he  was  sent  from  the  company  hospital  as  a  puzzling  case  to 
other  institutions.  Finally  he  arrived  at  the  Polyclinic.  He  was 
sent  to  the  Eye  Clinic,  to  the  Neurological.  Tests  were  made. 
Eyes  proved  normal,  spinal  fluid  negative  and  the  neurologist  re- 
ported no  delusions  and  no  homicidal  impulses.  Plainly  a  case  for  the 
Mental  Hygiene  Clinic.  Here  was  laid  bare  the  slackness  of  a  life 
spent  pottering  about  a  little  shop  in  his  home,  beginning  things,  but 
never  finishing,  unable  to  concentrate,  unequal  to  consecutive  effort. 
After  a  time  is  unearthed  a  disturbing  "complex" — the  rankling 


76  MENTAL  HYGIENE 

thought  of  his  divorced  wife,  the  thought  that  she  would  be  given  a 
share  of  salary  should  he  earn  one.  This  undoubtedly  acted  as  a 
subconscious  inhibition.  Further,  his  deafness  shutting  him  within 
himself,  had  deprived  him  of  wholesome  social  contacts.  The  psy- 
chologist at  once  undertook  to  re-educate  him  along  the  lines  of 
observation,  attention  and  concentration  and  to  stimulate  his  interest 
in  current  events.  It  was  a  painfully  slow  process,  for  eight  years  of 
desultory  existence  had  slackened  the  bowstring  of  will.  But 
gradually  he  was  led  back  to  healthy  habits  of  work.  He  is  now 
filling  a  good  position,  happy  and  useful  once  more. 

Little  Mary  Z.,  a  child  of  seven,  partially  crippled  and  nearly 
blind,  is  able  to  speak  only  14  words  and  her  chief  phrase  is  "I 
don't  want  to !"  Not  being  able  to  see  much,  she  tastes  and  smells 
whatever  arouses  her  curiosity.  After  she  had  been  sent  to  tuber- 
culosis, neurological  and  eye  clinics  and  a  Wasserman  test  had 
resulted  negatively,  the  doctors  could  only  recommend  glasses  and 
mental  training.  The  problem  is  to  ascertain  how  much  the  child 
really  sees  and  the  extent  to  which  the  words  she  uses  have  ac- 
tual meaning.  She  is  being  visited  three  times  a  week  and  under  the 
supervision  has  added  to  her  vocabulary,  has  learned  through  ex- 
ercises in  muscular  co-ordination  to  button  her  own  clothes  and  has 
become  amenable  to  suggestion.  After  two  months  she  has  been 
admitted  to  a  kindergarten — enlcouraging  progress  in  one  as- 
sumed to  be  hopelessly  handicapped. 

K.  D.,  a  boy  of  14,  was  sent  to  the  clinic  to  determine  his  fitness 
to  assist  in  the  support  of  the  family.  Found  to  be  a  dull  normal 
with  a  serious  heart  trouble  and  defective  vision  not  correctable  by 
glasses,  the  problem  was  this :  where  would  his  eye  defect  be  less  of 
a  handicap?  Would  he  develop  better  by  contact  with  life  than  with 
school-books?  To  what  extent  was  his  heart  trouble  a  handicap?  It 
was  decided  to  place  him  in  the  first  position  within  his  limitations 
which  should  give  promise  of  later  advancement;  not  to  thrust  him 
arbitrarily  into  a  job,  any  job,  any  blind  alley  occupation,  but  to 
place  him,  after  due  appraisement  of  his  resources,  his  possibilities, 
his  lacks,  with  full  opportunity  for  growth.  This  is  a  task  for  the 
psychologist,  in  accord  with  the  newest  idea  of  vocational  guidance 
and  rehabilitation  now  coming  into  recognition  with  war  time  needs. 

Mrs.  Y.,  the  temperamental  wife  of  a  coarse  Slavonian  waiter, 
became  the  victim  of  her  own  violent  temper  and  tendency  to  drink. 
Alarmed  at  the  murderous  impulse  which  had  driven  her  to  attack 
her  husband  with  a  pistol,  she  sought  the  Mental  Hygiene  Clinic. 
There  she  complained  of  his  irritating  ways,  his  inability  to  appre- 
ciate her  longing  for  "higher  things,"  and  of  her  children  whom  she 
found  a  great  burden.  The  social  worker  sent  to  report  conditions 


EFFECT  OF  MENTAL  HYGIENE  TREATMENT  77 

found  her  living  in  a  state  of  constant  agitation  and  domestic  chaos ; 
the  home  a  mess,  the  beds  unmade  at  4  p.  m.,  herself  still  in  curl- 
papers and  kimono,  absorbed  in  the  study  of  astrology.  The  husband, 
returning  to  this  state  of  things,  was  naturally  "irritating"— -there 
were  quarrels,  a  resort  to  alcohol,  a  family  at  the  point  of  disrup- 
tion. The  psychologist  is  now  re-educating  this  family ;  the  wife  has 
exercises  in  thought  control ;  she  keeps  an  emotion-chart  to  help  her 
to  present  a  serene  face  to  her  children ;  she  follows  a  weekly 
schedule  for  household  management.  Her  housewifely  sense  has  been 
stimulatd,  responsibility  for  her  children  awakened,  whiskey  is  ban- 
ished, and  gradually  her  brainstorms  are  becoming  less  frequent. 
There  are  occasional  relapses,  but  after  six  months'  training,  progress 
is  being  made  with  the  whole  family  group. 

Miss  Q.,  a  self-centered  failure  with  a  chronic  grievance,  drifted 
from  one  position  to  another,  always  looking  for  trouble,  always 
thinking  chance  remarks  and  casual  actions  were  aimed  especially 
against  her.  It  had  grown  to  be  almost  an  obsession  and  she  was 
fast  becoming  an  industrial  failure,  when  she  was  sent  to  the  Clinic. 
Here  she  was  trained  in  sane  thinking  and  feeling,  to  turn  her 
thoughts  out  instead  of  in,  and  today  she  is  filling  a  position  as 
nurse  satisfactorily  and  contentedly. 

Through  all  the  training  of  thoughts  and  feelings  there  is  a 
continuous  effort  to  lead  the  patient  outside  the  narrow 
walls  of  self  into  the  life  of  the  community.  Most  of  the 
"nervous"  and  insane  patients  are  out  of  harmony  with  their 
environment.  It  is  a  social  maladjustment.  To  get  them 
into  a  larger  life — to  make  them  feel  themselves  a  part  of 
the  striving,  courageous  world — is  to  lead  them  away  from 
dangerous  introspection.  The  need  of  a  living  philosophy  is 
emphasized.  Most  of  these  patients  had  muddled  along 
through  planless  days — their  lives  a  patchwork  of  ill- 
matched  activities,  miscellaneous,  heterogenous,  leading  no- 
where— save  to  nervous  breakdown. 


CHAPTER   NINE. 

PREVENTATIVE  MENTAL  HYGIENE 
That  part  of  mental  hygiene  which  has  a  prophylactic 
character  falls  into  two  classes,  group  preventative  mental 
hygiene,  and  individual  preventative  mental  hygiene.  Of 
the  first  kind  there  were  illustrations  in  the  discussion  of  the 
delinquent  boys  of  the  Ethan  Allen  School  where  the  im- 
portance of  imbuing  some  of  the  Italian  parents  with  higher 
ideas  in  regard  to  property  rights,  was  taken  up  and  also 
the  help  that  an  intelligent  policeman  might  be  in  inculcating 
proper  standards  in  a  neighborhood  in  regard  to  honesty  and 
right  action  in  general.  During  the  recent  influenza  epi- 
demic we  had  an  illustration  of  preventative  mental  hygiene. 
The  number  of  cases  of  influenza  hysteria  brought  to  the 
Emergency  Hospital  in  San  Francisco  decreased  after  peo- 
ple were  requested  to  wear  masks.  These  not  only  probably 
excluded  the  influenza  bacilli,  but  dispelled  the  fear  which 
would  have  rendered  the  body  more  susceptible  to  the  at- 
tack. Certain  insurance  companies  are  encouraging  their 
policy  holders  to  have  a  physical  examination  as  a  preventa- 
tive measure.  I  have  often  thought  that  a  mental  examina- 
tion might  set  most  of  us  to  work  to  making  an  effort  to 
bring  up  our  mental  activities  to  a  higher  standard. 

Individual  preventative  mental  hygiene  requires  of  course 
very  special  work.  In  looking  at  a  child  and  sometimes  at 
an  adult,  one  is  conscious  that  his  only  chance  of  having  a 
useful  and  happy  life  is  through  teaching  him  to  overcome 
and  replace  certain  accustomed  ways  of  thinking  and  feeling. 
The  work  of  the  clinical  psychologist  here  is  to  study  out 
what  is  a  given  individual's  normal  relation  to  the  world  in 
which  he  has  to  maintain  his  existence,  to  build  up  through 
imagination  a  clear  ideal  that  is  appropriate  and  possible  to 

78 


PREVENTATIVE  MENTAL  HYGIENE  79 

him,  and  through  persistent  and  patient  application  of  ap- 
propriate psychotherapeutic  methods  to  seek  to  transform 
not  alone  the  individual  himself,  but  sometimes  even  his 
environment. 

We  ought  to  do  more  than  we  are  now  doing  to  draw  the 
attention  of  parents  to  the  inadequancy  of  many  of  these 
ideals  and  to  urge  them  to  banish  the  tyrannical  disposition 
parents  sometimes  show  as  regards  the  impressing  of  their 
antiquated  and  outgrown  ideals  upon  their  children  and, 
through  doing  so,  making  them  failures — rendering  them 
not  alone  incapable  of  taking  their  place  successfully  in  the 
society  of  their  age  but  even  developing  in  them  incapaci- 
tating mental  disturbances.  Kaiserism  exists  in  far  too  many 
homes,  not  only  on  the  part  of  the  parent,  but  also  on  the 
part  of  some  of  the  children  who  have  an  obstinate  and  domi- 
nating nature.  One  of  the  problems  for  the  parent  to  solve 
is  not  only  to  control  his  own  tendency  to  an  interfering  and 
dominating  deportment,  but  also  to  see  to  it  that  exaggerated 
obstinacy  and  interference  are  suppressed,  or  at  least  con- 
trolled, on  the  part  of  the  children  in  dealing  with  each  other. 

Both  thought  and  emotion  are  instigators  to  action.  The 
experiences  of  the  last  two  years  had  so  often  shown  me  the 
importance  of  creating  more  healthy  emotional  main-springs 
of  action  as,  responsibility,  fine  feelings  (not  hate,  fear,  jeal- 
ousy, or  other  injurious  and  paralyzing  emotions),  that  I  re- 
cently prepared  a  pamphlet  for  the  California  Society  for 
Mental  Hygiene  (Publication  No.  4)  of  "the  Training  of 
the  Emotions,"  in  the  hope  that  later  some  one  else  would 
publish  a  leaflet  on  the  training  of  a  child's  thoughts  as 
action  stimulators.  What  follows  is  extracted  from  the 
pamphlet  just  mentioned : 

Emotion,  both  in  the  child  and  the  adult,  is  largely  the 
motivation  or  driving  force  as  regards  action.  Some  emo- 


8O  MENTAL  HYGIENE 

tions,  as  for  instance,  fear  and  rage,  appear  in  the  earliest 
days  of  infancy.  Manifestations  of  fear,  as  the  "sudden 
catching  of  the  breath,  the  clutching  randomly  with  the 
hands,  the  blinking  of  the  eye-lids,  the  puckering  of  the  lips, 
the  cry,  the  flight,  the  hiding,"  etc.,  are  often  brought 
about  by  the  careless  and  unconscious  actions  of  the  mother 
or  nurse — "by  the  sudden  pulling  of  the  blanket  when  the 
child  is  asleep,  by  a  sudden  push  or  shake  at  the  moment  of 
falling  asleep  and  of  awakening,  by  suddenly  removing  all 
support  as  when  it  is  dropped  upon  a  feather  pillow."  Fear 
of  the  dark,  which  is  very  common,  may  sometimes  arise 
from  the  inability  of  the  child  to  orientate  himself  and  move 
about  when  he  cannot  see,  but  is  usually  traceable  to  ter- 
rifying threats  and  stories  told  by  the  nurse  or  mother. 

When  will  we  really  take  cognizanze  of  Mosso's  words 
that  "every  fright  given  a  child  will  remain  like  a  minute 
splinter  in  the  flesh  to  torture  him  all  his  life  long." 

The  injurious  effects  as  regards  nervousness,  and  the 
inertia  and  even  paralysis  of  action,  which  can  be  traced  to 
early  fears,  are  far  too  common  in  later  life.  It  is  important 
therefore,  to  watch  from  earliest  infancy  for  the  expression 
of  obscure  terrors.  The  child's  direct  expression,  however, 
does  not  always  enable  one  to  ascertain  the  fundamental 
fears ;  but  we  have  a  means,  too  often  neglected,  of  discov- 
ering it  indirectly.  His  dreams,  and  his  restless  sleep  talk- 
ing, frequently  reveal  not  only  his  fears  but  his  other  emo- 
tional conditions  and  should  be  carefully  analyzed  in  order 
that  unhappy  reactions  may  not  become  penmanently  lodged 
in  the  mind,  to  distress  him  in  after  life.  A  curious  case 
which  was  directly  traceable  to  a  painful  experience  in  child- 
hood, was  recently  brought  to  my  attention.  The  patient 
had  a  phobia  (fixed  fear)  that  she  could  not  control  the 
movement  of  the  bowels  and  this  anxietv  had  come  to  dom- 


PREVENTATIVE  MENTAL  HYGIENE  8l 

inate  her  entire  life,  preventing  her  from  going  to  public 
gatherings  and  from  associating  with  her  friends,  and  this  in 
spite  of  the  fact  that  no  disaster  erf  the  kind  mentioned  had 
occurred  for  a  long  period  of  time  Such  seemingly  absurd 
phobias,  which  the  consulting  psychologist  is  frequently 
called  upon  to  eradicate,  are  more  common  than  is  generally 
supposed  and  are  often  connected  with  particular  places, 
which  may  be  termed  fear  centers.  There  are  a  number  of 
persons  in  San  Francisco  who  are  so  afraid  of  crossing  the 
Bay  on  the  ferries  that  they  permit  their  nervousness  to  de- 
termine their  actions  and  tfieir  places  of  residence. 

To  know  how  to  control  and  banish  temporary  and  fixed 
phobias  is  as  important  from  the  standpoint  of  physical  as  of 
mental  health.  Recent  experiments  have  shown  that  fear, 
rage,  and  other  unhealthy  emotions  play  a  decided  role  in 
stomach  difficulties  and  even  in  producing  certain  bodily 
deformities.  One  of  the  physical  methods  used  by  the  con- 
sulting psychologist  to  eradicate  fear  is  based  on  the  fact 
that  fear  and  its  bodily  expression  are  closely  connected.  It 
cannot  be  doubted  that  to  assume  the  expression  of  rage  or 
fear  is  to  cultivate  and  develop  them.  When  afraid,  psy- 
chology says:  take  the  bodily  position  that  is  its  opposite 
— relax,  breathe  out,  imitate  the  position  of  courage — and  the 
fear  will  tend  to  disappear.  Again :  fatigue  and  fear  are 
closely  associated  and  proper  rest  periods  are  therefore  one 
of  the  best  means  of  preventing  apprehensions.  Certain 
psychological  exercises  may  be  used  to  control  emotion, 
particularly  those  having  to  do  with  attention.  Directing  the 
attention  to  any  emotion,  intensifies  it,  while  diverting  the 
attention  decreases  it.  In  the  case  of  fear  the  attention  must 
be  turned  from  the  fear-arousing  center  and  the  bodily  ex- 
pression which  accompanies  it.  Building  up  pleasant  asso- 


82  MENTAL  HYGIENE 

ciations  with  unpleasant  or  fearsome  phenomena  is  another 
psychological  method:  a  child  who  had  been  frightened  by 
the  screams  of  children  in-a  neighboring  hospital  was  taught 
to  associate  them  with  the  joyous  shouts  of  children  jumping 
from  the  spring  boards  at  the  baths.  Still  another  psycholog- 
ical method  is  to  implant  healthy  and  motivating  ideas  so 
firmly  in  the  mind  that  they  will  have  power  to  prevent  the 
undesirable  emotion  which  has  been  habitually  rising  to 
disturb  the  mental  equilibrium,  and  to  direct  the  physical 
actions.  Quotations  which  express  strikingly  and  sugges- 
tively the  healthful  attitude,  may  be  used  to  inhibit  morbid 
emotions.  Persons  are  often  told  to  avoid  the  centers  or 
locations  which  arouse  fear ;  but  this  is  certainly  a  mistaken 
treatment,  for  definite,  fixed  fears  are  seldom  isolated  entities 
— they  are  rather  a  strong  expression  of  shirking  from 
difficulties  in  general  or  of  a  complexity  of  apprehensive 
feelings.  What  such  a  person  needs  is  to  be  taught  to  learn 
to  stand  up  and  face  the  situation. 

Rage,  as  well  as  fear,  is  discernible  in  a  child  from  the 
very  first.  Watson3  has  found  that  the  stiffening  of  the 
body,  the  striking  movements  of  the  hands  and  arms,  the 
drawing  up  of  the  feet  and  legs,  the  holding  of  the  breath 
until  the  face  is  flushed,  the  slapping,  biting  and  pushing, 
exhibited  by  children  is  produced  by  hampering  their  move- 
ments. Almost  any  infant  can  be  thrown  into  a  rage  by 
holding  its  arms  tightly  to  its  sides  or  by  clamping  the  elbow 
joint  with  the  fingers,  or  by  merely  placing  its  head  be- 
tween cotton  pads — the  best  natured  child  will  show  rage  if 
its  nose  is  held  for  a  few  seconds.  From  these  demonstra- 
tions we  can  see  that,  unconsciously  in  the  nursery,  a  men- 
tal condition  is  often  created  which  becomes  injurious  to 
the  adult  and  which  sometimes  results  in  a  permanent  state 
of  nervous  irritability.  In  measuring,  by  a  spring  balance, 


PREVENTATIVE  MENTAL,  HYGIENE  83 

the  strength  put  forth  by  an  angry  baby,  I  came  to  realize 
the  waste  of  energy  in  anger  and  to  see  why  people  are 
terribly  exhausted  and  even  ill  after  getting  into  a  rage. 

The  relation  between  parental  affection  and  the  mental 
habits  of  children,  especially  in  the  case  of  only  or  favorite 
children,  is  very  intimate.  Injurious  complexes,  i.  e.,  associa- 
tions of  ideas,  are  built  up  which  interfere  with  the  child's 
adjustments  in  later  life.  Exaggerated  dependence  is  some- 
times seen  when  the  child  continually  hangs  on  its  mother's 
skirts;  and  premature  independence  is  displayed  in  a  gen- 
eral "I  won't"  attitude  towards  its  parent.  Some  parents  in- 
sist on  excessive  affection  and  unquestioning  acceptance  of 
their  ideas  on  the  part  of  their  children.  The  habit  of  imi- 
tating the  parent  thus  set  up  not  only  results  in  the  taking  on 
of  the  conventional  habits  of  the  station  in  which  the  family 
moves,  but  it  prevents  the  development  of  that  mental  ini- 
tiative which  leads  to  invention  and  discovery  in  all  direc- 
tions. The  originality  which  should  be  fostered  by  family 
training  and  on  which  social  progress  depends,  is  thus 
defeated  by  excessive  affection.  Autocratic  tendencies, 
whether  in  parents  or  in  children  toward  each  other,  should 
be  suppressed,  even  though  it  is  necessary  that  in  many 
matters  the  child  should  be  taught  to  obey  instantly  and 
cheerfully.  Much  of  the  inattention  complained  of  at  school 
is  due  to  the  fact  that  the  child  has  not  been  taught  to 
"stand  at  attention"  when  spoken  to;  and  is  in  part  the 
result  of  the  parents'  not  giving  attention  when  the  child 
speaks  to  them. 

The  primary  emotions,  rage  and  fear,  are  but  a  fraction 
of  the  whole  range  of  emotions  of  which  human  nature  is 
capable  in  adult  life.  Training  should  be  directed  early  to 
narrowing  the  expression  of  the  unhealthy  emotions  and  to 


84  MENTAL  HYGIENE 

broadening  the  capacity  for  happy  and  wholesome  feelings. 
Jealousy,  which  is  at-  the  root  of  much  of  the  paralyzing 
criticism  among  adults,  must  be  rooted  out ;  suspcion,  which 
may  later  result  in  ideas  of  persecution,  must  be  destroyed; 
the  habit  of  depression  and  anxiety  must  be  combated  by 
habitually  smiling  and  a  courageous  attitude  toward  life. 
Moods  in  which  fixed  periods  of  elation  and  depression 
alternate,  that  is,  which  have  a  manic  depressive  coloring 
and  upon  which  young  persons  sometimes  pride  themselves, 
should  be  discouraged,  since  they  may  be  the  starting  points 
of  nervous  difficulties,  not  to  say  of  insanity. 

Rewards  and  punishment,  speaking  generally,  are  the 
instruments  for  training  the  child ;  but  before  suitable  reward 
or  punishment  can  be  meted  out,  one  must  become  acquainted 
with  the  child's  likes  and  dislikes  The  rewards  and  punish- 
ments employed  by  the  mother  are  often  inadequate  and  not 
adapted  to  the  individual  child.  The  words  "Wait  till  I  get 
you  home"  are  too  often  heard.  Deferred  penalties  are  in- 
effective because  the  child  forgets  the  act  for  which  the 
punishment  is  given ;  while  constant  threatening  teaches  him 
to  think  that  in  the  particular  case  he  may  escape.  The 
mother  needs  instruction  along  these  lines  and  at  every 
Health  Center  there  should  be  a  mental  hygiene  adviser,  a 
psychologist  who  not  only  examines  into  the  emotional  life 
of  the  child  but  is  competent  to  give  advice  concerning  his 
emotional  and  mental  training. 

REFERENCES. 

1.  BARKER — Principles  of  Mental  Hygiene  Applied  to  the  Man- 

agement of  Children  Predisposed  to  Nervousness. 

2.  CANNON — Bodily  Changes  in  Pain,  Hunger,  Fear  and  Rage. 

3.  JENNINGS,  WATSON,  MEYER  and  THOMAS— Suggestions 

of  Modern  Science  Concerning  Education. 

4.  FREUD— On    Dreams. 

5.  BRUCE — Hardships  of  Childhood.     (A  popular  summarization.) 


CONCLUSION 

At  present  the  consulting  psychologist  has  to  justify  his 
existence  through  showing  that  he  has  not  only  a  knowledge 
which  fits  him  to  supplement  the  work  of  the  physician  as 
regards  the  treatment  of  psychopathological  conditions ;  but 
also,  on  examining  the  mental  disturbances  enumerated  in 
Table  III,  one  sees  that  the  "squatter's  right"  gives  the  con- 
sulting psychologist  a  claim  to  many  different  kinds  of  cases, 
the  care  and  treatment  of  which  had  not  previously  been 
provided  for.  To  handle  properly  the  various  classes  of  cases 
that  belong  by  right  to  him  the  psychologist  must  have  dif- 
ferent, and  such  special  preparation  that  many  other  special- 
ists than  those  dealing  with  feeble-mindedness  and  delin- 
quency will  doubtless  arise  in  the  field  of  psychological 
therapeutic  work. 

In  thinking  over  future  work  in  clinical  psychology,  in  the 
light  of  my  past  two  years'  experience,  what  comes  to  me 
is  that  the  success  of  the  person  who  works  in  this  field 
will  be  measured  largely  for  a  long  time  to  come,  by  his  abil- 
ity to  assist  others  in  coping  with  two  great  sets  of  problems : 
i,  those  growing  out  of  epidemics  such  as  the  recent  influ- 
enza; and  2,  of  the  rehabilitations  necessitated  by  the  war. 
In  both  cases  it  will  be  a  question  of  bringing  a  given  indi- 
vidual to  the  point  of  readjusting  his  mode  of  thinking, 
feeling,  and  doing.  This  means  that  every  person,-  even  the 
child  whose  ideas  and  modes  of  action  are  patterned  after 
those  of  his  elders, — that  is,  along  old  lines, — must  make 
himself  over  or.be  made  over,  if  he  is  successfully  to  keep 
and  improve  his  place  in  society.  Some  persons,  probably 
the  majority,  can  themselves  meet  an  emergency  promptly 

85 


86  MENTAL  HYGIENE 

and  satisfactorily,  but  many  are  so  fixed  in  their  ways  of 
thinking  and  feeling  that  only  through  the  aid  of  those  who 
have  a  scientific  knowledge  of  applied  psychology,  will  they 
be  made  able  to  cope  with  the  problems  of  a  changed  every- 
day life.  Such  persons  are  not  sufficiently  mobile  mentally ; 
their  intellectual  and  physical  reactions  are  far  too  firmly 
fixed.  The  problem  of  the  mental  hygiene  adviser  will  be 
to  assist  them  through  applying  psychological  principles  and 
exercises,  to  break  up  old  stable  mental  and  emotional  com- 
plexes without  too  great  strain,  and  to  re-combine  their  ele- 
ments into  new  complexes  which  are  in  harmony  with  the 
present  time  and  which  will  possess  adequate  energizing 
power  for  the  individual's  participation  in  a  new  world. 


A  CHILD  HISTORY  BLANK  OF  THE  MENTAL  HYGIENE 

CLINIC 

at 

M.  H.  No.  Clinic  No. 

Date  Age  Years  Months 

I.  Name  Residence 

Referred  by  Telephone 

History  recorded  by  Social  Worker 

Name  and  relation  to  the  patient  of  person  giving  history. 

II.  Complaint  of  the  patient   (time,  character,  cause  of  the  onset 
of  the  psychosis). 

III.  Summary  of   previous  medico-psychological   examination   and 
treatment. 

IV.  Physical  examination : 

(a)  Height     feet          inches ;  weight        pounds ;  nourishment. 

(b)  Condition  of  eyes,  need  of  glasses,  total  or  partial  blind- 
ness,   myopia,    hyperopia,    strabismus,    astigmatism ;    ears 
(deaf,     deafmutism ;     size,     setting,     conformation,     and 
lateral    symmetry   of   ears);    mutism;    nose    (adenoids); 
throat     (tonsils)  ;    teeth     (shape,    irregular,    absent,    en- 
larged incisors,  condition  and  care)  ;  fingers   (clubbed)  ; 
shape  and  length  of  trunk  and  limbs;  feet,  special  shoes 
needed;  well  or  poorly  nourished. 

(c)  Any  physical   peculiarities   indicating   feeble-mindedness. 

(d)  Speech:  stuttering,  stammering,  lisping  (Use  test  words). 


CONCLUSIONS  87 

(e)  Reaction  type   (i.  e.,  active,  lithe,  etc.) 

(f)  Motor  power;   ability   to   form  and  break  down  condi- 
tioned  reflexes. 

(g)  Sleep    (crying  out  in   sleep,   sleep-walking)    and   dreams, 
bed    wetting,    masturbation,    restless    behavior. 

(h)      Bad  habits  (as  biting  nails,  sucking  lip,  drooling,  placing 
tongue  in  abnormal  positions,  etc.) 

V.  Examination  of  the  general  health  condition : 

(a)  Food    (meat,   eggs,   starch,   fats,   milk,   sugar  vegetables, 
fruits,  excessive  candy  eating)  ;  drink,  (coffee,  tea,  milk, 
alcohol);  manner  of  eating;  time  of  eating   (eating  be- 
tween meals);   digestion;   condition   of  bowels;   retiring 
and  rising  hour;  number  of  hours'  sleep;  place  of  sleep- 
ing ;  ventilation ;  day-rest  hour ;  convulsions,  vertigo,  in- 
somnia,  nervousness. 

(b)  Diseases  child  has  had :  Rickets,  scrofula,  any   form  of 
tuberculosis,  convulsions,  measles,  scarlet  fever,  whooping 
cough,     diphtheria,     mumps,     meningitis,     brain     fever, 
chorea,    paralysis,    nervous    symptoms    or   attacks,    faint- 
ing and  dizzy  spells,  spasms ;  age  at  first  menstruation ; 
accidents. 

VI.  Examination,  personal  development  history,  and  reactions : 

(a)  Race  birthplace          religion. 

(b)  Pregnancy    and    birth     (normal,    premature,    exceptional 
conditions  of  birth,  accidents). 

(c)  Age  of  walking          talking          acquiring  tidy  habits. 

(d)  Only   child,   youngest,    favorite. 

VII.  Examination  of  family,  social  and  industrial  conditions : 

(a)  Race  birthplace  religion   of   father,   mother  and 
child. 

(b)  Number  of  sisters  and  brothers          age,  occupation  and 
wages.    If  in  school,  grade. 

(c)  Occupation  of  father  and  mother;  wages; 
practical   and    economic   knowledge   and   efficiency;    lan- 
guage spoken  at  home. 

(d)  Economic,    moral,    social,    and    health   conditions    of    the 
home    (broken   home,    subjective   and   objective   causes), 
and  neighborhood.     (Grade  each,  separately  from  I.  ex- 
cellent, to  IV.  poor.) 

(e)  Neighborhood.  Temptations,  (saloons,  fruit  stores,  freight 
yards,  etc.)     Character  of  neighbors.     Name  and  attitude 
of  the  policeman. 

(f)  Character  of  amusements;  best  moving  pictures  you  have 
seen,  cards,  prize  fights,   music,  dances,  athletics ;   read- 
ing (kind  of  newspapers  and  books  and  content,  murders, 
disaster,   burglary). 


VIII.  Heredity  and  family  history  as  to  alcoholism  and  drug  hab- 

its, feeble-mindedness,  insanity,  eccentricities  and  peculiari- 
ties, convulsions,  suicide,  crime,  tuberculosis,  etc. 

IX.  Psychological  examination : 

(a)  Reports   of   child's  behavior  at  home,  mode  of  playing, 
ability  to  get  on  with  other  children,  moral  character  and 
disposition,    truancy,    lying,    pilfering,    thieving,    fighting, 
running    away — reason;    lazy,    seclusive,    moody,    social, 
anti-social,   cheerful,   sulky,    selfish,    slovenly,    neat,    sissy 
or    cry-baby,    sly,    jealous,    bashful,    nervous,    sensitive, 
depressed,     emotional,     aftectionate,     complaining,     teas- 
ing, gossipy,  very  changeable,  proud   (of  what),  resent- 
ful, obedient,  destructive,  violent,  cruel,   fear    (of   dark, 

animals,  etc.),  queer  ideas,  courageous,  anxious,  romanc- 
ing, unfeeling,  obstinate,  easily  discouraged,  laughing  or 
crying  without  cause,  hiding  things. 

(b)  Child's  personal  care  of  himself;  feeding  himself,  dress- 
ing himself,  buttoning  his  clothing,  tying  his  shoes. 

(c)  School  progress;  age  of  entrance;  terms  kept  out;  why; 
attendance,  present  grade,  grades  skipped  and  repeated ; 
school    marks    in    reading,    writing,    spelling,    arithmetic, 
language,  geography,  history; 

conduct  present  teacher's  name 

school  teacher's  estimate  of  the  child  as 

regards  intellectual  ability  and  conduct. 

(d)  Details  of  any  delinquencies  or  exceptional  behavior  on 
part  ot  tiie  cnild,  hypersensitiveness,  spells  of  rage,  peri- 
odic  depression,      punishment   intlicted,   and   the   child's 
attitude    to    correction,    efiorts    made    to    help    mm,    Dy 
whom  and  with  what  results.''    Has  he  been  under  juve- 
nile Court? 

Why?  Under  whose  guardianship? 

(e)  Outline   of   child's   behavior   on   the  play-ground   and   in 

the  play-room  with  toys  and  simple  pieces  ot  apparatus 
ior  physical  exercise,  which  throws  light  on  his  disposi- 
tion, character,  and  interests. 

(f)  Vocational  tendencies:  the  child's  ambitions  and  instinctive 
likings   and   activities,   his   amenableness   to   training   in 
fields  liked   and  disliked,   training  methods   most  avail- 
able with  him. 


CONCLUSIONS  89 

(g)  Brief  history  of  child's  life  to  date,  his  treatment  at 
home,  morals,  associates  and  their  influence,  his  work, 
use  of  wages,  employer's  opinion  of  him,  his  chief  in- 
terests and  amusements,  use  of  leisure  time,  habits;  gen- 
eral information  as  to:  President  of  U.  S.,  Allies,  Lin- 
coln, Washington,  Ocean  near  San  Francisco,  what  is 
flour  made  from,  cost  of  a  pair  of  shoes,  who  are  the 
White  Sox,  Tigers,  Giants,  what  is  the  easiest  job,  most 
dangerous,  and  anything  else  of  importance  not  stated 
elsewhere. 

(h)  Summary  of  psychological  examination;  sensorism  (smell, 
taste,  touch,  hearing,  sight),  orientation,  illusions  and 
hallucinations,  delusions,  memory  (remote  and  recent), 
imagination,  attention,  flow  of  thought,  voluntary  (will), 
(what  did  you  see  on  your  way  to  the  clinic)  and  in- 
voluntary movements,  (tics,  origin),  emotional  char- 
acteristics. Results  of  Terman  or  Yerkes-Bridges  mental 
tests  and  of  special  tests,  to  determine  ability  to  form 
practical  judgments  in  new  situations,  habits,  of  observa- 
tion, center  of  interest,  attention,  association,  learning 
type  (by  direct  instruction  or  by  doing)  any  indication  of 
the  child's  being  dull,  subnormal,  delinquent,  psychopathic, 
insane,  supernormal. 

X.  Enumeration  of  the  other  clinics  to  which  consulters  were  re 
ferred  and  the  reports  on  the  child's  physical  condition. 

XI.  Provisional  mental  diagnosis,  prognosis,  and  psychotherapy. 


790 
M3S" 


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